Angiofibroma on cheek mucosa: a rare entity and its management with laser.

A rare presentation of an angiofibroma in the oral cavity is reported, which was treated with a diode laser. The benefits of laser treatment include bloodless procedure with instant precise coagulation of vessels. Although rare and unusual, it is suggested that angiofibroma should be included as one of the differential diagnoses of soft tissue swellings in the oral cavity.

INTRODUCTION

Angiofibromas are highly vascular, histologically benign but locally aggressive tumours, predominant in the nasopharynx as reported in the literature. Extra nasopharyngeal localization of this tumour is rare. These tumours can appear as a result of infection, trauma, hormones and arterio-venous malformation.[1] Within the group of angiofibromas, the giant cell variant, lipomatous variant and the atypical variant with very close clinical features are the ones which can be differentially diagnosed.[2]

CASE REPORT AND MANAGEMENT

An 87-year old female patient reported to the Department of Periodontology with complaint of a “grape-like” swelling on the left cheek since 4 years which grew slowly to reach the present size without any pain creating discomfort while mastication. Intra-oral examination revealed a well-defined solitary, pedunculated, oval growth on left buccal mucosa measuring about 1.5 cm × 1 cm, with colour similar to adjacent mucosa [Figure 1]. On palpation, the growth was soft, non-tender, non-fluctuant and doughy in consistency. Based on the above findings, a provisional diagnosis of lipoma was made with a differential diagnosis of fibroma and angiofibroma.

Figure 1

Clinical view of the swelling

The growth was excised from the base of the peduncle [Figure 2] with the diode laser (FONA Laser, Germany) set on excision setting at 1.5 W power and continuous mode and sent for histopathological examination. The margins were merged with the surrounding tissues. A pectin dressing (Oraplast™) was applied. Analgesic, multivitamin and chlorhexidine mouth rinse were prescribed. There were no specific complaints 6 weeks postoperatively [Figure 3].

Figure 2

Per-operative -Excision of swelling by dental diode laser

Figure 3

Post-operative view- after six weeks

Histopathological examination

Histopathology revealed stratified squamous epithelium with flattening of rete ridges, fine and coarse collagen fibrils with an irregular, pattern. The vascular network was of varying calibre, irregular in shape, consisting of proliferating endothelial lining and few inflammatory cell infiltrates chiefly plasma cells [Figure 4]. It was reported as angiofibroma.

Figure 4

Histopathological microphotograph – showing stratified squamous epithelium and fibro-vascular connective tissue

DISCUSSION

Angiofibromas are commonly well circumscribed tumours, localised in the superficial soft tissue and characterised by bland spindle-shaped cells arranged within vessels. Flucke et al. reported a link between cellular angiofibroma, spindle cell lipoma and mammary type myofibroblastoma showing a spectrum of one entity with morphological variations dependent on anatomic location.[3] The diagnosis of angiofibroma is dependent more on histological confirmation due to its close resemblance with other lesions, such as angiomyoma, haemangioma, lymphangioma and haemangiopericytoma. Even for an experienced pathologist accurate diagnosis of an angiofibroma is difficult when its location is an extremely rare one.[4]

We have used a dental diode laser for excision due to superior haemostasis and no sutures are required. There is minimal post operative oedema and scar formation.[5]

CONCLUSION

It is to emphasise that angiofibroma, although rare and unusual, should be included in the differential diagnosis of soft tissue swellings in the oral cavity and can be managed by surgical excision or laser.