A Rare and Atypical Manifestation of Intraosseous Hemangioma in the Zygomatic Bone.

Intraosseous hemangiomas (IH) are rare intrabony lesions that represent less than 1% of intraosseous tumors. IH are mostly seen in the axial skeleton and skull. Most commonly, the frontal bone, zygomatic, sphenoid, maxilla, ethmoid, and lacrimal bone can manifest IH. Currently, IH is classified as a developmental condition of endothelial origin. According to WHO, the five histological types of IH are cavernous, capillary, epithelioid, histiocytoid, and sclerosing. IH of the zygoma is an extremely rare condition with female predominance. A systematic review recently estimated that there were 78 cases published in the literature until 2023. The lesion is usually asymptomatic and presents with a gradually deteriorating deformity of the malar area, and the patient might be able to recall a history of trauma. Numbness due to involvement of the infraorbital nerve might also be present; however, atypical skin and bone sensations might also occur. Other symptoms include painful swelling, bone asymmetry, skin irritation, sinus pressure, paresthesia, diplopia, enophthalmos, or atypical neuralgia. A bony lesion with a trabecular pattern in a radiating formation (sunburst pattern) or a multilocal lytic lesion pattern created by the multiple cavernous spaces (honeycomb pattern) is commonly observed during radiologic evaluation. We present a rare case of IH of the zygoma in a 65-year-old generally healthy woman. A cyst-like bone tumor was revealed from the CT scan, which made preoperative biopsy of the lesion problematic. A careful radiological diagnostic differentiation of the lesion should always be conducted in such cases to outline a safe surgical plan and possible alternatives if needed. The patient underwent total tumor resection in the operating room, and the defect was reconstructed with the use of a titanium mesh and a synthetic hydroxyapatite bone graft based on a 3D surgical guide printed model.