What are the most common buccal masses in infants?

Most Common Cheek Masses in Infants

Hemangiomas are the most common cheek masses in infants, followed by lymphangiomas (cystic hygromas), with these vascular lesions accounting for the vast majority of buccal masses in this age group. 1, 2

Epidemiology and Distribution

• Hemangiomas represent approximately 59% of all salivary gland region masses in children, making them by far the most common lesion 2
• Lymphangiomas account for approximately 28% of masses in the salivary gland region 2
• Among oral tumors specifically, the cheek (buccal mucosa) is the third most common location (19% of cases), after lips and tongue 1
• Infantile hemangiomas occur in 4-5% of all infants, with the head and neck being the most common anatomic site 3, 4

Key Distinguishing Features

Infantile Hemangiomas

• Appear in the second week of life with rapid and progressive growth, not present at birth 5
• Female predominance of 1.4-3:1 5
• Premature birth and low birth weight are significant risk factors, with 25% increased risk for every 500g reduction in birth weight 5
• Raised, well-defined vascular lesions that are readily distinguished from flat capillary malformations 3
• Undergo characteristic proliferative phase followed by gradual involution, with 90% of involution complete by age 4 years 5

Lymphangiomas (Cystic Hygromas)

• Represent 23% of hamartomatous lesions in the oral cavity 1
• May require occasional re-excision after initial surgical treatment 1
• Often present as bulky lesions in the head and neck region 6

Clinical Decision Algorithm

When evaluating a cheek mass in an infant:

1. Timing of appearance: Lesions appearing in weeks 2-4 of life strongly suggest infantile hemangioma 5

2. Physical characteristics:

   • Raised, well-defined borders → hemangioma 3
   • Cystic, compressible mass → lymphangioma 1

3. Growth pattern: Rapid proliferation in first months → infantile hemangioma 3, 5

4. Imaging confirmation: Ultrasound with Doppler is first-line, showing high-flow arterial and venous waveforms in hemangiomas 5

Management Considerations

For infantile hemangiomas requiring treatment:

• Propranolol 2-3 mg/kg/day divided into 2-3 doses is first-line therapy for complicated or high-risk lesions 5
• Treatment should start as soon as possible to prevent tumor growth and typically continues until age 12 months 5
• Cardiovascular evaluation (heart rate, blood pressure, cardiac auscultation) is mandatory before starting propranolol 5

For lymphangiomas:

• Simple surgical resection is the primary treatment, though re-excision may be necessary 1

Important Caveats

• Not all hemangiomas involute completely: 10-20% require post-adolescent ablative treatment 7
• Segmental hemangiomas in "beard distribution" (lower face and neck) require airway evaluation for subglottic involvement 3
• Large facial segmental hemangiomas warrant PHACE syndrome evaluation (posterior fossa malformations, hemangioma, arterial anomalies, cardiac defects, eye anomalies) 5
• Solid tumors account for only 13% of salivary region masses in children, with benign lesions (87%) far outnumbering malignant ones (13%) 1, 2