0:01

So this is a friend of mine, actually, who presented

0:05

with this bluish discoloration over his right lip.

0:09

Just basically where the top, the, the, the

0:12

two lips meet, we referred to that as the incisura,

0:15

and they were wondering what this lesion was.

0:18

So we did an MR, and we did all the

0:21

regular sequences, and if we look

0:24

at the T2-weighted images of the top right

0:26

hand corner, I'm gonna point out the normal

0:28

anatomy on the patient's left-hand side.

0:30

Here's our buccinator muscle here.

0:32

Here's our masseter muscle here.

0:34

This guy right here is a parotid duct that pierces

0:37

the buccinator muscle, and this region right here

0:40

is the buccal region in the buccal space.

0:42

So what we have here in this patient is

0:44

a mass that's involving the right buccal

0:47

space, which is part of the oral cavity.

0:50

And you can actually see the parotid

0:51

duct extending right into it.

0:53

So what we see here is a lesion that's high signal

0:56

on T2, and when we look real closely, we can see

1:00

that there's actually different types of high signal.

1:02

There's one that's a little bit

1:03

grayer and a little bit brighter.

1:05

And with the leap of faith, we can

1:07

actually see some air-fluid levels here

1:09

that are layering within this lesion.

1:11

So this tells us that this is cystic, and part

1:14

of this cystic fluid actually contains protein.

1:18

When we give contrast, we can

1:19

see that there's no enhancement

1:21

within this region.

1:22

So this is not a solid mass, it's a

1:24

cystic mass, so it's a cystic lesion

1:27

involving the buccal space that has fluid.

1:30

When we also look on the T2-weighted images,

1:32

we can see these focal areas of decreased T1 signal,

1:36

and these probably represent small little phleboliths.

1:40

So what we have right now is a congenital cystic

1:43

lesion that's involving the right buccal space

1:46

that's involving the buccinator muscle.

1:48

And with the involvement of the muscle,

1:50

you also have small little phleboliths.

1:53

So this is a type of congenital vascular malformation.

1:57

And when I think of congenital vascular malformations,

2:00

the easiest way to think about it, and this

2:02

will get you through about 80% of these, is that

2:05

you have lesions that involve the lymphatics.

2:08

You have lesions that involve capillaries.

2:10

You have lesions that involve veins,

2:12

and lesions that involve arteries.

2:15

When you have overlaps of these rings, this allows you

2:18

to have different types of vascular malformations.

2:21

So in this case, we have a cystic

2:23

lesion involving the buccal space.

2:24

So that tells us that we have something that's

2:27

lymphatic in origin. When we have a component

2:31

that involves the muscles and also contains phleboliths,

2:33

this is characteristic of a venous malformation.

2:37

So if you have, um, components that

2:40

are lymphatic and venous in origin,

2:42

this is what we refer to as a veno-

2:44

lymphatic malformation. And veno-

2:47

lymphatic malformations, because they typically

2:49

contain a little bit of blood, oftentimes give

2:52

you a little bit of hemorrhage, and that would

2:54

explain that fluid-fluid level that we see.

2:58

When we do the dynamic contrast-enhanced study,

3:00

We really don't see much

3:01

appreciable enhancement at all.

3:03

So the primary components are the following.

3:06

This is a congenital vascular malformation

3:10

with the primary components being lymphatic and

3:12

venous, hence the term veno-lymphatic malformation.