Case report of a large hemangioma of the parotid gland with multiple phleboliths and tonsilloliths

Hemangiomas are benign vascular deformities characterized by an increased proliferation and turnover of endothelial cells. They account for the majority of parotid gland tumors in infants but are rare in adults. Changes in blood flow dynamics within hemangiomas can cause stasis, thrombus formation and phleboliths. Tonsilloliths are calcifications occurring primarily within the palatine tonsillar crypts. We report the case of a large hemangioma of the parotid gland with multiple phleboliths and tonsilloliths in an adult, highlighting the clini cal and imaging features on panoramic radiography, Cone Beam Computed Tomography (CBCT), cervical ultrasound, Magnetic Resonance Imaging (MRI) and Doppler imaging. A 20-year-old woman presented, complaining of a painless swelling below her right ear. Panoramic radiograph showed multiple randomly distributed round-to-oval radiopaque structures overlying the right mandibular ramus. CBCT revealed several radiopaque structures in the right palatine tonsillar crypts. Cervical ultrasound exposed a large heterogeneous and predominantly hypoechogenic mass in the right parotid gland. MRI displayed a well-defined lesion in the right parotid gland extending into the parapharyngeal pre-styloid space, hypointense on T1 and hyperintense on T2, containing several nodules. The diagnosis was: large hemangioma of the right parotid gland extending into the parapharyngeal pre-styloid space, with multiple phleboliths and tonsilloliths. Propranolol was delivered, with periodic follow-up on Doppler images, showing a hemangioma size reduction. Standard radiographs can detect tonsilloliths and phleboliths but additional imaging modalities disclose the exact diagnosis and location of calcifications and the diagnosis, structure and extent of the vascular lesion. Tonsilloliths and phleboliths should be considered in the differential diagnosis of radiopaque masses involving the mandibular ramus. Hemangioma with phleboliths should be considered in the differential diagnosis of parotid tumors when numerous intraglandular calcification nodules are detected on radiographs.