Cavernous hemangioma of the frontal bone.

A 44-year-old man presented with a 1-year history of a right forehead mass. Over the previous 3 months, he had begun to feel increasing pressure and discomfort around the mass. On physical examination, the palpable mass was present over the right brow (figure, A). Findings on the remainder of the head and neck examination were unremarkable. Computed tomography (CT) of the head identified a well-circumscribed lytic mass that involved the anterior table of the right frontal sinus (figure, B). On CT, the lesion measured approximately 11 mm at its greatest dimension.

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The anterior table of the right frontal sinus was resected, along with mucosal stripping for tumor removal (figure, C). The supraorbital rim was reconstructed with a molded titanium mesh covered by hydroxyapatite cement (Mimix; Walter Lorenz Surgical; Jacksonville, Fla.). The cement was contoured to the defect. Histopathology was consistent with an intraosseous cavernous hemangioma.

Calvarial hemangiomas account for 20% of all hemangiomas but only 0.2% of all bone neoplasms. (1) Hemangiomas account for 1% of all bony neoplasms. (1) These neoplasms most commonly arise in the vertebral bodies, but when they do occur in the cranial bones, the frontal and parietal locations are most common. Hemangiomas are classified as capillary, cavernous, or mixed, based on their histology. Microscopic examination will reveal hamartomatous proliferations of vascular tissue within endothelium-lined spaces. (1)

The treatment of choice for calvarial hemangiomas is surgical resection with immediate reconstruction. Large lesions may require preoperative angiography with embolization. Reconstruction with autogenous bone (e.g., a calvarial bone graft) is the gold standard. Graft material can be harvested through the same incision. Alloplastic materials have also proven to be useful. They are expedient, and they can provide similar cosmetic results without the risk of donor-site morbidity. In 2003, Eppley et al reported a series of 62 patients who had undergone cranioplasty with Mimix hydroxyapatite; 5% of these patients developed an infection that required removal of the implant material. (2)

References

(1.) Clauser L, Mandrioli S, Polito J, Galie M. Surgical techniques for the removal of forehead hemangioma. J Craniofac Surg 2006; 17(4): 702-4.

(2.) Eppley BL, Hollier L, Stal S. Hydroxyapatite cranioplasty: 2. Clinical experience with a new quick-setting material. J Craniofac Surg 2003;14(2):209-14.

Sofia Avitia, MD; Ryan F. Osborne, MD, FACS 

From the Osborne Head and Neck Institute, Los Angeles.