CASE PRESENTATION
We report a case of a 6-month old girl referred to the Nairobi hospital with a massive, progressively growing congenital mass in the oral cavity. A thorough medical history revealed no co-morbidities with all vital signs within normal limits. Upon physical examination, the patient was found to have difficulty in breathing, difficulty feeding and inability to close the mouth. Intra oral examination revealed a large swelling involving more than two thirds of the tongue, most of which lay outside the oral cavity (figure 1) . The lesion was a deep red-purple colour, soft on palpation, non-tender and normal in temperature with no appreciable thrills but blanched on application of pressure. Examination of the surrounding structures was unremarkable.
Magnetic Resonance Imaging (MRI) with gadolinium revealed a well-circumscribed soft tissue mass measuring 3.9cm x 4.1cm x 5.8cm. It involved most of the tongue except for the base and extended to both lateral borders, while inferiorly, involved the entire thickness of the tongue to its ventral surface. The mass was hypointense on T1-weighting and was found to be hyperintense on T2- weighting. Multiple low signal foci were noted which were compatible with flow voids (Figure 2) . Digital subtraction angiography revealed the feeder vessels to be anomalous branches of the lingual arteries. These findings, coupled with blood collection in the interior of the lesion, informed the diagnostic hypothesis of a congenital lingual hemangioma.
The lesion was monitored closely over a period of 1 year with the expectation of improvement by involution, however, the lesion showed no signs of reducing in size and in fact enlarged over this duration (Figure 3 ). After a multidisciplinary discussion, immediate embolization of the feeder vessels and subsequent surgical resection of the lesion was proposed in order to improve the quality of life for the patient and prevent fatal airway obstruction. Embolization of the lingual arteries (LA’s) was performed through a transfemoral approach. Using the bilateral lingual arteriograms, the feeder vessels from the right and left LA’s were selectively embolized as close to the lesion as possible using absorbable gelatin sponge particles (Gelfoam, 100 to 200 μm) under fluoroscopic guidance. Post-embolization angiograms of the LA’s were performed to confirm if all feeder vessels had been occluded (Figure 4)
One month post embolization, a colour change from deep red/purple to a lighter shade was noted and the lesion seemed to have reduced slightly in size slightly as shown by its surface having mucosal folds as opposed to appearing stretched and shiny prior to embolization (figure 5 ). Despite this, feeding and airway management were still a major problem for the patient. A month later, naso-tracheal intubation under endoscopic guidance was performed and a modified key hole surgical technique was used to reduce the bulk of the lesion (figure 6 ). A full thickness elliptical wedge incision was made on the dorsum of the tongue using electrocautery, accompanied by two diverging incisions on the anterior portion of the tongue. Hemorrhage was controlled by compression of the posterior aspect of the tongue using moist gauze after which excess tissue from the central and anterior portion of the tongue was excised. Suturing was done in various planes using vicryl 3.0 after attaining the best fitting of the tongue into the oral cavity. In the immediate post-operative period, there was slight swelling of the tongue which resolved in a few days.
Postoperative hospital stay was uneventful with no medical or surgical complications. The patient was fed via a nasogastric tube for a period of 5 days after which it was removed and oral feeding begun. The patient was discharged on the 8th day after surgery. Histology of the tissue specimen revealed the diagnosis to be a capillary hemangioma (figure 7 ). At the final follow up visit, the tongue had healed entirely and could fit within the mouth comfortably. The patient showed marked improvement in speech and swallowing functionality with no other complaints (figure 8 and 9 ).