What Does Venous Lake Mean (VL)?
Venous lake (VL) is considered a benign vascular tumor that occurs in the head and neck region and affects older individuals. This also goes by the medical terminology colloquially known as senile hemangioma or phlebectasia. VLs present themselves clinically as soft, compressible papules or nodules in the head and neck region. These may be dark blue, purple, or red-colored lesions manifesting especially in the oral cavity. These are commonly located at the lower lips of elderly people (above the sixth or seventh decades of life).
Although this lesion is usually asymptomatic, its presence can cause significant cosmetic concerns and lead to aesthetic discomfort or distress regarding the patient's appearance. When the clinical symptoms of VL start in an individual, which are usually occasional bleeding or painting lesions of the lower lip or in any specific region of the head and neck, it may further cause physical, emotional, aesthetic, and social discomfort to the patient. Most of the VL lesions do not possess any tendency to spontaneously involute or resolve on their own. If they are not self-resolving in a few weeks, then treatment is certainly required to improve the cosmetic appearance and prevent recurrent bleeding to relieve the patients of the mental stress associated with the appearance of these deep-colored nodules. Histopathologically, VL is known to exhibit very clear dilated vascular spaces with red blood cells, erythrocytes, and thrombi that are scattered in the fibrous stroma.
Why Is Differential Diagnosis So Important?
VL is easy to diagnose for the oral and maxillofacial surgeon in cases that have the typical presentation of the features listed above. Dentists would need to establish a confirmative diagnosis because it is quite easy to confuse these lip lesions with other oral-pigmented lesions, such as the labial melanotic macule (LMM) or oral malignant melanoma (OMM). Owing to their potential dark color and nodularity, VLs on the lips may often appear similar to LMM or OMM lesions. Hence, differential diagnosis is the key to establishing a confirmative diagnosis. The treatment modalities are also different for these oral diseases; VL is a vascular tumor, whereas IMM and OMM are melanocytic lesions.
The surgeon or dentist may recommend the procedure of dermoscopy, which is a non-invasive diagnostic tool for detecting various pigmented or non-pigmented cancers or tumors. The diagnosis of VL cannot be established histologically or through dermoscopy alone. Clinical features of the patient are taken into consideration, such as the occurrence of VL nodules or lesions in the sun-exposed or sun-hit areas of the face, neck, helix of the ears, and lips (a common location for occurrence in elderly patients) that needs evaluation. This presentation is correlated with a histological observation, typically of a structure less pattern manifesting with globules or clouds associated with dilated vascular spaces.
What Is the Comparison of Clinical Features?
The mean onset age is around 60 to 65 years (sixth to seventh decade of life), whereas, in LMM (labial melanotic macule), lesions usually occur in the fourth or fifth decade of life, with females more prevalent than males.
- The lesions in VL are soft, compressible, dark blue, and flat. They can even resemble dome-shaped papules or nodules in the lower or upper lip, with the lower lip being the common location of occurrence.
- In LMM, the surgeon observes only single, discrete, brown-to-black macules.
- Oral malignant melanomas (OMM), which are the other differential diagnosis to be considered for VL lesions, are much rarer, accounting for 0.1 to 8 percent of all melanomas.
- These are different from both VL and LMN lesions because the predominance in males is more often solitary, with brown to black macules appearing as patches or nodules showing asymmetry with irregular borders. Ulcerations are also common in OMM lesions.
What Are the Treatment Strategies for Venous Lake Lesions?
Various treatments have been suggested by physicians and maxillofacial surgeons in the medical literature. These include the consideration of the following modalities:
- Surgical excision is the mainline strategy or therapy.
- Cryosurgery.
- Sclerotherapy.
- Electrocoagulation.
- Laser Therapy: Laser and light-based modalities for complete elimination and prevention of lesion recurrence. Examples include the pulsed dye laser and long-pulsed (1064 nm), the neodymium:yttrium‐aluminum‐garnet (NdYAG) laser, and others. Laser treatment is preferred in light of current surgical trends for managing orofacial lesions, as it minimizes patient discomfort, reduces post-treatment scarring, and significantly lessens the occurrence of scarring following surgical excision. Moreover, laser treatment offers the added advantage of high efficacy, effectively preventing the frequency of lesion recurrence postoperatively.
As elaborated earlier, the differentiation of VL and LMM is crucial in a clinical setting so that the dentist can select the appropriate laser modalities as well as consider the right treatment parameters. Similarly, as mentioned earlier, though dermoscopic evaluation would certainly prove a helpful noninvasive diagnostic tool in the diagnosis of VL, very few reports exist in the medical literature to truly differentiate the lesions from other similar lesions of LMM or OMM (labial melanotic macule and oral malignant melanoma).
Conclusion
Venous lake disease affects the head and neck; hence, it requires a clear differential diagnosis from the labial melanotic macules and oral melanotic macule lesions by the oral and maxillofacial surgeon. Surgical excision and laser therapy would be necessary for large nodules on the lower lip. It would be a severe source of esthetic and physical distress for the patient. Laser surgery can prevent post-operative scarring or improve esthetics after surgery in affected patients.
