September 2019 HSC Section 1 Congenital and Pediatric Problems

Yuhan et al

typically present at birth, do not regress, and grow in proportion to the child. Rapid expansion of the lesion, however, is associated with 2 common complications: con- current infection and intralesional hemorrhage. 15 Although diagnosis remains primarily clinical, prenatal ultrasonography is an increasingly popular mode of confirmatory imaging. 16,17 Management is individualized and often depends on the degree of functional impair- ment. Conservative management, including proper oral hygiene and regularly sched- uled dental prophylaxis, should focus on reducing infectious complications, which have been reported to be as high as 80% in the literature. 14 Both sclerotherapy and surgical excision have been shown equally efficacious although they tend to be more effective in lesions greater than 2 cm in diameter. 9,18 Venous malformations Venous malformations (VMs) are present at birth and appear as compressible bluish- purple lesions found on mucosal membranes of the oral cavity and airway, and in certain muscle groups. 19 Dependent drainage of venous blood leading to expansion may be elicited by leaning a child back in Trendelenburg position and on crying. 13 In- vasion into adjacent tissue and static blood may lead to acute thrombus formation with calcification and severe pain, which is unique to VMs. 20 Similar to lymphangio- mas, VMs grow in proportion with the growth of the patient. Doppler ultrasonography shows a low-flow lesion with compressible hypoechoic vessels. 21 MRI may be used to distinguish this from other high-flow lesions seen intra- orally, such as an arteriovenous malformation, which is rare in children. 22 Multimodal approaches to treatment, involving a combination of conservative man- agement, sclerotherapy, laser therapy, or surgical excision, depends on proximity to vital structures and depth of involvement. The effectiveness of surgical excision de- pends on the characteristics of the lesion. Those with poorly defined borders and extensive invasion into normal tissue have the potential for severe blood loss. 8 Pyogenic granuloma Pyogenic granulomas involve focal areas of vascular proliferation in response to local trauma. 23 Despite the name, they are not true granulomas but are benign vascular tu- mors. 24 Described as a lobulated mass, oral pyogenic granulomas are usually red, painless, and slow growing ( Fig. 2 ). 25 When seen in a pregnant woman, they are termed granuloma gravidarum . Most intraoral lesions are found on the gingiva (75%), may extend between teeth, and are likely due to poor oral hygiene. 26 Because they are friable, bleeding is usually the primary complaint. 23 Treatment involves full- thickness surgical excision. Recurrence occurs in up to 16% of all cases and may necessitate re-excision. 27 Cysts and pseudocysts of the minor salivary glands are considered the most prevalent cysts of the oral cavity. 8 In the pediatric population, a majority of mucoceles are seen on the buccal mucosa and palate. 28 Clinically, they present as translucent, fluctuant, smooth masses that are bluish in color when superficial. One study showed sponta- neous regression in 43.8% of all cases of mucoceles in their pediatric population. 28 Definitive treatment, however, usually involves complete surgical excision of the un- derlying minor salivary gland lobules to prevent recurrence. 29 Mucoceles that develop due to extravasation of mucin from sublingual glands or mi- nor salivary glands in the floor of the mouth are called ranulas. They appear as large blue, fluctuant masses lateral to the midline ( Fig. 3 ). Large ranulas that extend through Cysts and Pseudocysts Mucoceles and ranulas

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