Intramuscular hemangioma presenting with multiple phleboliths: a case report A. Zeynep Zengin, DDS, PhD, Peruze Celenk, DDS, PhD, and A. Pinar Sumer, DDS, PhD A rare case of intramuscular hemangioma of the masseter muscle with multiple phleboliths is described, highlighting features evident in plain radiography, ultrasound, and magnetic resonance imaging (MRI). A 21-year-old woman presented with a complaint of swelling of the right masseter muscle. A plain radiograph from the soft tissue of the right cheek showed a large number of round, target-like radiopacities that varied in size. Ultrasound revealed a lobulated cystic lesion in the right masseter muscle with increased echogenicity. MRI showed a space-occupying lesion in the right masseter muscle, which was isointense on T1-weighted image close to the muscle tissue and hyperintense on T2-weighted image, containing fields with no signal septations. A plain soft tissue radiograph can demonstrate phleboliths and aid in the diagnosis of an intramuscular hemangioma. In addition, nonionized techniques such as ultrasound and MRI can provide useful information to clinicians regarding the location of calcifications and the structure of masses. (Oral Surg Oral Med Oral Pathol Oral Radiol 2013;115:e32-e36) Developmentally, intramuscular hemangiomas (IMHs) represent congenital vascular malformations. 1 The pre- dominant complaint is the presence of a slowly enlarg- ing mass. IMHs are classified according to their histo- logic appearance as either capillary, cavernous, or mixed small/large vessel types. They generally develop in patients during the first 3 decades of life 2 with no gender predispositions. Fifteen percent of IMHs occur in the head and neck region, 2,3 with the masseter muscle is the most common site. 4 The differential diagnosis of a mass in the mas- seter muscle includes benign muscular hypertrophy, lymphadenopathies, a sialocele of the parotid gland duct, and various parotid and muscle neoplasms. 1,5 Phleboliths are calcified thrombi that are a charac- teristic feature of hemangiomas, occurring in 15%-25% of IMHs. 2,3,6 They are generally variable in size, 7 found in multiple number, and cause no subjective symptoms. The diagnosis of IMHs can be difficult, because of the deep intramuscular location, rare incidence, and lack of specific symptoms that suggest a vascular-origin lesion. Definitive preoperative diagnosis has been re- ported in 8% of cases. 8 Although standard radio- graphs are simple and constitute an important diagnos- tic tool in diagnosing the phleboliths within the mass, 5 other diagnostic imaging modalities, such as comput- erized tomography (CT), magnetic resonance imaging (MRI), 9,10 and ultrasound. 11 also play a significant role in the preoperative diagnosis of IMHs. To the best of our knowledge, no previous study has included plain radiography, ultrasound, and MRI im- ages of an IMH with phleboliths in the maxillofacial region. The present report describes an IMH of the masseter muscle with multiple phleboliths, highlighting the features evident in plain radiography, ultrasound, and MRI. CASE REPORT A 21-year old woman presented with a complaint of swelling of the right masseter muscle causing a cosmetic deformity. The swelling had been present since 6 months of age and had gradually grown as the patient aged. A temporary increase in the size of the mass was observed when the patient cried, laughed, or performed handstands. Besides caries on the right upper first molar, no dental disease was observed. The patient’s medical and family history were unremarkable. On physical examination, there was asymmetry to her face (Figure 1). Bimanual palpation of the right cheek revealed a mass with hard nodules of various sizes. The mass was immobile and could not be definitively separated from the masseter muscle or the parotid gland. There were no bruits or pulsation present. Intraoral examination revealed normal-col- ored mucosa and normal discharge from the right parotid gland. Periapical films from the soft tissue of the right cheek (Figure 2) and the decayed upper right first molar (Figure 3) showed large numbers of round target-like radiopacities vary- ing in size from 2 to 10 mm. Based on radiographic and clinical findings, the lesion was suspected to be a sialolith or phlebolith, and the patient was sent for ultrasound and MRI, respectively. Ultrasound examination showed a lobulated cys- tic lesion, 2  5 cm in size, located in the right masseter Department of Maxillofacial Radiology, Faculty of Dentistry, Uni- versity of Ondokuz Mayis, Samsun, Turkey. Received for publication Dec 26, 2011; returned for revision Feb 19, 2012; accepted for publication Feb 25, 2012. © 2013 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter http://dx.doi.org/10.1016/j.oooo.2012.02.032 Vol. 115 No. 1 January 2013 e32