Involution of a large parotid hemangioma with oral propranolol: an illustrative report and review of the literature

Pediatric Salivary Gland Pathology

Benign and malignant salivary gland disorders are uncommon in the pediatric population; however, these can be frequently seen in pediatric otolaryngology or oral and maxillofacial surgery practices. The astute clinician should be aware of the clinical presentation, diagnosis, and management options for common inflammatory, infectious, benign, and malignant disorders of salivary glands.

A Large Parotid Hemangioma Managed Successfully with Propranolol

The treatment of parotid hemangiomas has posed a challenge. A male infant presented with large hemangioma of the right parotid gland diagnosed at the age of 3 months. Starting at the age of 4 months, he was treated with oral propranolol for 10 months, which led to a marked reduction in tumor size and strawberry hemangioma. Our case shows that propranolol is effective and safe in treating large parotid infantile hemangioma.

Evaluation of the efficacy and safety of topical timolol maleate combined with oral propranolol treatment for parotid mixed infantile hemangiomas

The aim of the present study was to assess the efficacy and safety of topical timolol maleate combined with oral propranolol for parotid infantile hemangiomas. Between October 2012 and April 2014, propranolol was administered orally at a dose of 1.0-1.5 mg/kg/day to 22 infants with proliferating hemangiomas in the Department of Oral and Maxillofacial Surgery (Hospital of Stomatology, China Medical University, Shenyang, Liaoning, China). A small amount of 0.5% timolol maleate eye drop solution was topically applied with medical cotton swabs to the area of the lesion twice a day, every 12 h. The study group consisted of 9 males and 13 females, aged 2-9 months, with a median age of 4.7 months. The lesions were all located in the parotid region, and measured between 3.5×4×0.5 and 7×8×3 cm in volume. The planned duration of therapy was 6-8 months, or the two drugs were stopped when complete regression of the lesions was obtained. The therapeutic outcomes and safety were assessed by the change in the size and color of the tumor, and the presence of adverse effects throughout the course of treatment. The mean duration of therapy was 21.1 weeks and ranged from 3 to 8 months. Of the 22 patients, 16 demonstrated an excellent response, 6 showed a good response and 2 displayed a moderate response. No major collateral effects were observed. Overall, oral propranolol combined with topical timolol maleate may be used as the first-line therapeutic choice in the treatment of infantile parotid mixed hemangioma.

Efficacy of topical brimonidine-timolol for haemangioma of infancy and perils of off-label prescribing

We report three patients with superficial haemangiomas treated topically with Combigan ophthalmic solution (brimonidine 0.2%-timolol 0.5%), a combination selective α-2-adrenergic agonist and non-selective β-blocker Food and Drug Administration-approved for use in glaucoma. Topical brimonidine 0.2%-timolol 0.5% therapy improved the appearance of haemangiomas in all the cases. Two patients did not experience any adverse effects. One patient had hypothermic episodes which were initially thought to be because of brimonidine 0.2%-timolol 0.5% therapy. However, an episode occurred a few weeks after discontinuation and brimonidine 0.2%-timolol 0.5% therapy was ruled out as a cause. Despite the benefit, off-label use of brimonidine 0.2%-timolol 0.5% therapy served as a pitfall in the evaluation of an unusual constellation of worrisome symptoms. In conclusion, brimonidine 0.2%-timolol 0.5% therapy is a promising alternative in the topical treatment of haemangiomas. It may have synergistic effects and increased efficacy by targeting haemangiomas via two mechanisms (α-agonism and β-inhibition), but the risk of unforeseen adverse effects must always be considered when prescribing off-label treatment, especially in infants.