A 5-month-old female infant presented with swelling in the region of both cheeks extending below the jaws, first noticed as a peanut sized swelling 3 months earlier. On examination, there were bright red, bosselated, non tender, non-fluctuant masses in the area of both parotid glands involving most of the cheeks, and both submandibular salivary glands. Overlying skin showed a fine network of capillaries with excoriation on the left side (Fig. 1, 2). The infant was born at term, was developmentally normal and growing well. Ultra-sonography (USG) revealed enlargement of bilateral parotid, and submandibular salivary glands, lobular structure with fine echogenic internal septations. Color Doppler demonstrated numerous blood vessels within the mass confirming hemangiomas of the glands. Treatment with oral propranolol was started at 2 mg/kg/day in 3 doses; however the patient was lost to follow-up.

Fig.1 Hemangioma involving left parotid and submandibular glands with superficial excoriation.	Fig. 2 Hemangioma affecting right parotid gland.

Salivary gland tumors are rare in children, most common are hemangiomas and the parotid is most commonly affected. They present as focal lesions or as part of a segmental distribution involving the V3 mandibular segment as in our patient. Segmental hemangiomas are more aggressive, have a prolonged growth phase, higher likelihood of associated ulceration, airway obstruction, and soft-tissue and cartilage destruction. Diagnosis is confirmed by USG, rarely requires MRI. Lesions to be considered in the differential diagnosis of a parotid hemangioma include cystic lymphatic malformations (cystic hygromas). These do not have a solid component as seen by USG or MRI in PH. Solid lymphatic malformations may extend beyond the parotid and do not contain prominent blood vessels. A rhabdomyosarcoma may arise in the head and neck region, but is rare in infancy, is less vascular and infiltrates into neighbouring structures. Congenital infantile fibrosarcoma of the parotid, though very vascular on Doppler sonography has a non-homogeneous structure. A solitary infantile myofibromatosis in the parotid region may show rapid growth followed by involution, however these are ill defined and not vascular. A sialoblastoma (congenital carcinoma) is a rare tumor of the salivary glands of infancy and can be differentiated from a PH on US or MRI because it is non homogeneous and less vascular.

Most PH involute spontaneously; 10 % require active management. Recommended therapy includes intra-lesional corticosteroids for small lesions, systemic corticosteroids or interferon alfa-2a or -2b for large ones and more recently oral propranolol. Surgical correction is recommended in the involuting or involuted phases (preceded by sclerotherapy).