Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Hemangiomas of the Head and Neck Hemangiomas are benign vascular anomalies which may occur in various areas throughout the body with 50% being located in the head and neck. Vascular anomalies are the most common head and neck tumor in infancy and childhood with hemangiomas and lymphatic malformations comprising the majority of these lesions. Classification Although the classification systems vary for vascular tumors, Mulliken's scheme divides hemangiomas into two categories, capillary and cavernous. Capillary hemangiomas are the most common with an incidence of 1-1.5% in infants. They are characterized by raised, circumscribed, red lesions that are often lobulated. On histology, they are composed of small thin-walled vessels of capillary size that are lined by single layer of flattened or plump endothelial cells and surrounded by discontinuous layer of pericytes and reticular fibers. .In general, they are low flow lesions. Cavernous hemangiomas on the other hand can be high flow lesions, and they consist of deep, irregular, dermal blood-filled channels. They typically impart a purple-blue hue to the overlying skin. They are comprised of tangles of thin-walled cavernous vessels or sinusoids that are separated by a scanty connective tissue stroma. Further classification includes a mixed hemangioma containing both components which may be more common than the pure cavernous lesions. Clinical Course Hemangiomas are usually not present at birth but are antedated by a pale, well-circumscribed flat area that may contain some central telangiectasia. The actual hemangioma will appear within the first month and will continue to increase in size for the next 3-8 months. A stable phase of relatively no growth then occurs over the next 6-12 months followed by slow involution of the tumor by ages 5-7 years. They can occur just about anywhere in the head and neck, but are more common in the parotid, lip, oral cavity, perinasal region, and larynx or subglottis. The complications of these lesions are ulceration, infection, bleeding, compression syndromes (airway compromise), thrombocytopenia, and even high output cardiac failure. Psychiatric problems are not uncommon given the sever cosmetic deformities that are associated with facial tumors. Treatment There is no uniformly accepted treatment of head and neck hemangiomas. The various modalities of therapy are dependent upon the age of the patient, the site and size of the lesion, and the hemodynamic flow of the hemangioma. It is important to note that congenital lesions typically regress while adult onset lesions do not. The treatment options include: observation, steroids, embolization, cryotherapy, sclerotherapy, antifibrinolytic agents, radiation therapy, laser photocoagulation, surgery with or without preoperative embolization, or any combination of the above. Observation is encouraged in uncomplicated cases given the natural regression with onset in infancy, but intervention should be considered with lesions that threaten function. Steroids may act to increase the sensitivity of the hemangioma to circulating vasoconstrictors, but the overall mechanism is unclear. Dosing can range from 20 to 40 mg per day and have been continued from 2 weeks to 17 months. The various side effects of prolonged steroid therapy are many and must be considered when following a patient on steroid therapy. Other modalities such as antifibrinolytic agents, cryotherapy, and sclerotherapy have shown variable efficacy in reducing the size of the hemangioma and are not generally considered as first line therapies. Radiation therapy has fallen out of favor because of its potential to disrupt growth and induce malignancies. Laser Treatment The use of the laser to treat hemangiomas by photocoagulation or excision has become popular with the advent of new laser technology. The argon laser emits a blue-green light that is absorbed by hemoglobin as well as melanin, and has only a few millimeters of penetration. It is therefore more useful for superficial lesions, and may cause skin pigmentation changes as a result of its effects on melanin containing cells. The copper vapor laser emits a light that is selectively absorbed by hemoglobin and thus it has reportedly less effects on the skin. Its range of penetration is similar to that of the argon laser and so is limited to use with superficial lesions. The CO2 laser has minimal tissue penetration (.2-.5mm) and therefore is a valuable tool for subglottic hemangiomas where limited penetration will protect the nearby esophagus and great vessels. The Nd-YAG laser has low tissue absorption and thus deeper penetration (5-7mm), and it is also preferentially absorbed by pigmented soft tissue. These characteristics make it especially useful for the deeper cavernous or mixed hemangiomas. The YAG laser can also be transformed into a hemostatic excisional tool by utilizing the scalpel tip adaptor. Surgery Surgical excision appears the most effective treatment and often results in complete cure. It is reserved for small lesions that fail to regress or the larger lesions that compromise function or cause severe cosmetic deformity. Superselective embolization is recommended pre-operatively in order to reduce the complications of bleeding that can occur. The use of the laser as a pre-operative coagulator can also be utilized in conjunction with surgical excision. Summary Hemangiomas are common tumors of the head and neck. The majority of congenital lesions will regress spontaneously, whereas adult onset lesions will persist. There are many options for treatment when a lesion fails to regress or compromises function. In general, surgical excision with a combination of embolization or laser photocoagulation pre-operatively is the treatment of choice. Case Presentation A 57-year-old female first noted a vascular growth on her face in 1981. It began as an approximately 1 cm lesion on the lateral right alar base and slowly progressed. She has undergone one standard surgical excision and one laser excision with recurrence each time. She complains not only of the cosmetic deformity but also nasal obstruction and intermittent bleeding. Her past medical history is significant for Hashimoto's thyroiditis and her medications are thyroxine and premarin. Physical exam revealed a soft, raised, bluish mass over the right nasal ala extending into the vestibule. She underwent pre-operative superselective angiography and embolization of the tumor and feeder vessels off the distal internal maxillary artery the day prior to surgery. Surgical excision was performed with the contact tip, YAG laser scalpel, with less than 5 cc blood loss. Reconstruction was performed with a nasolabial flap to recreate the alar and upper lip and cheek defect. A full thickness skin graft from the supraclavicular region was used to cover the nasal floor. Bibliography Apfelberg DB, Maser MR, White DN, et al. Combination treatment for massive cavernous hemangioma of the face: Yag laser photocoagulation plus direct steroid injection followed by YAG laser resection with sapphire scalpel tips, aided by superselective embolization. Lasers in Surg and Med 1990;10:217-33. Azzolini A, Bertani A, Riverti C. Superselective embolization in immediate surgical treatment: our present approach to treatment of large vascular hemangiomas of the face. Ann Plast Surg 1982;9:42-60. Bartlett JA, Riding KH, Salkeld LJ. Management of hemangiomas of the head and neck in children. J Otolaryngol 1988;17:111-20. DiBartolomeo JR. Response of vascular lesions of the head and neck to argon laser radiation. Otolaryngol Head Neck Surg 1983;91:203-6. Fradis M, Podoshin L, Simon J, Lazarov N, Shagraw I, Boss JH. Combined treatment of large head and neck capillaro-venous malformations by a fibrosing agent. J Laryngol Otol 1089;103:390-8. Fredrickson JM. Radiation-induced carcinoma in a hemangioma. Otolaryngol Head Neck Surg 1979;87:584-6. Gongloff RK. Treatment of intraoral hemangiomas with nitrous oxide cryosurgery. Oral Surg 1983;56:20-4. Govrin-Yuhudain J, Moscona AR, Calderon N, Hirschowitz B. Treatment of hemangiomas by sclerosing agents. Ann Plast Surg 1987;18:465-9. Hawkins DB, Crockett DM, MacLaughlin EF. Corticosteroid management of airway hemangiomas: long-term follow-up. Laryngoscope 1984;94:633-7. Hurwitz DJ, Futrell JW. Congenital vascular malformations and hemangiomas. In: Cummings CW, Krause CJ, editors. Otolaryngology - Head and Neck Surgery. St. Louis: C.V. Mosby, 1986: 261-78. Key JM, Waner M. Selective destruction of facial telangiectasia using a copper vapor laser. Arch Otolaryngol Head Neck Surg 1992;118:509-13. Knoior RJ, Holinger LD, Russell EJ. Superselective embolization of laryngeal hemangioma. Laryngoscope 1988;98:830-4. Li ZP. Therapeutic coagulation induced in cavernous hemangioma by use of percutaneous copper needles. Plastic Reconstr Surg 1992;89:614-22. McCaffrey TV, Cortese DA. Neodymium:Yag laser treatment of subglottic hemangioma. Otolaryngol Head Neck Surg 1986;94:382-4. McHenry C, Jarosz H, Calandra D, et al. Thyroid neoplasia following radiation therapy for Hodgkins lymphoma. Arch Surg 1987:122:684-6. Mulliken JB. Classification of vascular birthmarks. In: Vascular birthmarks: hemangiomas and malformations. Philadelphia: WB Saunders, 1988:24-7. Persky MS. Congenital vascular lesions of the head and neck. Laryngoscope 1986;96:100215. Rebeiz E, April MM, Bohigian BK, Shapshay SM. Nd-YAG laser treatment of venous malformations of the head and neck: an update. Otolaryngol Head Neck Surg 1991;105:655-61. Robertson SJ, Wiegand DA, Schaitkin BM. Life-threatening hemangioma arising from the parotid gland. Otolaryngol Head Neck Surg 1991;6:858-62. Schild SE, Buskirk SJ, Frick LM, Cupps RE. Radiotherapy for large symptomatic hemangiomas. Int J Radiat Oncol Biol Phys 1991;21:729-35. Shapshay SM, David LM, Zeitels S. Neodymium-YAG laser photocoagulation of hemangiomas of the head and neck. Laryngoscope 1987;97:323-30. Shelton C, Brackmann DE, Lo WM. Intratemporal facial nerve hemangiomas. Otolaryngol Head Neck Surg 1991;104:117-21. Subglottic hemangiomas in infants: treatment with CO2 laser. Laryngoscope 1984;94:638-41. White CW, Sondheimer HM, Crouch EC, et al. Treatment of pulmonary hemangiomatosis with recombinant interferon alfa-2a. N Engl J Med 1989;320:1211-12. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
|