Postcricoid Hemangioma of Childhood: Report of Four Cases

Congenital Laryngeal Hemangioma: A Case Report of a Rare Presentation

Pediatric vascular anomalies are classified into vascular malformations and vascular tumors. While vascular malformations are generally anomalous vessels, vascular tumors arise from endothelial cells characterized by abnormal proliferation. Vascular tumors, also called hemangiomas, are subdivided into infantile and congenital hemangiomas. The differentiation of these anomalies can be challenging, and immunohistochemical staining is often employed for this purpose. The GLUT-1 (erythrocyte-type glucose transporter protein) stain is positive for the infantile type. Hemangiomas are usually found in the head and neck region. Their occurrence in the laryngeal region in infants tends to manifest in the subglottic region. Hemangiomas in the larynx mostly do not cause any symptoms until they are large enough to cause dyspnea, stridor, or hoarseness of voice. They are mostly treated in infants with propranolol or surgical excision. We report a case of an eight-day-old female infant who presented with a mass that recurrently protruded out of the mouth when she cried. The mass stopped protruding out of the mouth when the baby became restless, had respiratory distress, and refused feeds. Endoscopy of the pharynx and larynx showed a pedunculated hemorrhagic mass attached by a stalk to the left arytenoid. With cautery, the stalk of the lesion was severed from its attachment. The baby was discharged on the fourth postoperative day and histology reported a cavernous hemangioma. Seven months after the surgery, the baby is growing normally. Yearly follow-up endoscopies have been scheduled to evaluate for recurrence or residual disease.

Systematic review of pediatric postcricoid cushion and postcricoid lesions

OBJECTIVES

It is thought that many infants have a prominent venous plexus of the postcricoid area. In the past this entity had occasionally been reported as a postcricoid hemangioma or even a postcricoid mass. The term postcricoid cushion is now gaining acceptance to describe the prominent venous plexus of the posterior cricoid area. Although it rarely causes symptoms, it should be considered when patients present with symptoms of obstruction. Differentiating between normal variant postcricoid prominent venous plexuses, hemangiomas, and vascular malformations can be difficult and cannot be confirmed without immunohistochemistry. The objective of this systematic review is to describe current practices, clinical symptoms, management and outcomes of pediatric postcricoid lesions including postcricoid cushion.

METHODS

A systemic review of the literature was done using the PRISMA (Preferred Reporting Items for Systemic Reviews and Meta-Analyses) guidelines to investigate postcricoid lesions. The following terms: Postcricoid, Postcricoid lesions, Postcricoid mass, Posterior cricoid, Pressure-dependent postcricoid mass, postcricoid prolapse, postcricoid hemangiomas, postcricoid vascular malformations, and postcricoid cushion were searched in PubMed and Google Scholar. Articles that were within the inclusion criteria were reviewed. Demographics, past medical and birth histories, clinical symptoms, evaluations, biopsy results, treatments, and outcomes were included. For the purposes of this review, postcricoid cushions, pressure-dependent postcricoid mass, and postcricoid prolapse will be group under normal variant postcricoid cushion.

RESULTS

15 articles with 42 distinct cases were included in this systemic review. 21/42 of the patients were female, the age ranged from 2 days to 18 years, the median age was 6.5 months, and 39/42 of patients were under the age of 2 years. 17/42 patients were diagnosed "hemangiomas" in the papers with only 1 case confirming the diagnosis of hemangioma with immunohistochemistry. 7/42 were diagnosed vascular malformations with 3 cases confirming the diagnosis of with immunohistochemistry. 17/42 of cases were normal variant postcricoid cushions. Most commonly, patients had a history of laryngomalacia (14/33) followed by no other medical history (9/33). The most common clinical symptoms were stridor, dysphonia, or weak cry in 30/42, dysphagia in 20/42, sleep disordered breathing in 9/42, and regurgitation or aspiration in 9/42.8/38 of patients diagnosed with postcricoid cushion did not have visualization of the lesion until a Valsalva maneuver was performed. The most common management for "hemangiomas" was observation (8/17), for "vascular malformations" was laser therapy (3/7), and for normal variant postcricoid cushions was observation (8/17). The most common outcome was complete resolution (14/30) followed by improvement of symptoms (9/30), and residual complications (4/30) The median time to follow-up was 12 months.

CONCLUSION

Due to the relatively new "discovery" of the normal variant postcricoid cushion, including postcricoid cushion, pressure-dependent postcricoid mass, and postcricoid prolapse, the majority of the literature are case reports. Although it is theorized that many children under the age of 2 have a prominent venous plexus, in some cases it could cause symptoms of obstruction. Because immunohistochemistry is rarely done and reported in the literature, many case reports may have misdiagnosed the postcricoid lesions. Also, in many cases visualizing the normal variant postcricoid cushion requires that the patients have increased intrathoracic pressure; therefore, if no postcricoid prominence is seen initially or when the patient is under general anesthesia and a postcricoid lesion is suspected, the patient should receive a Valsalva maneuver or be placed in Trendelenburg position. Most cases of normal variant postcricoid cushions can be managed with observation. Due to the rarity and novelty of the discovery, more research needs to be done on the management of symptomatic postcricoid lesions and differentiating between normal variants and pathological vascular lesions.

Postcricoid haemangioma with laryngomalacia in infancy

Infantile haemangioma represents a congenital vascular anomaly commonly observed in the head and neck region. Such an occurrence over the postcricoid region, however, is rather unusual. Herein, the authors report a case of a synchronous postcricoid haemangioma in a 7-week-old newborn diagnosed with severe laryngomalacia. In addition to the floppy redundant arytenoid mucosa, flexible laryngoscopy revealed a lobulated bluish mass at the postcricoid. The lesion was hyperintense on T1-weighted sequence and was enhanced with contrast, supporting the diagnosis of a haemangioma. She underwent surgical excision of the haemangioma with intralesional steroid injection. Surveillance at 6-month postoperation did not show disease recurrence.

A rare case report of an solitary neurofibroma in postcricoid region of hypopharynx

RATIONALE

Postcricoid neurofibroma is an extremely rare hypopharynx tumor that can be challenging in both diagnosis and treatment. This case sheds light on the possibility of treatment with transoral microsurgery before pursuing open cervical incisions.

PATIENT CONCERNS

: A 43-year-old man presented with a four months history of a persistent foreign body sensation and mild dysphagia. Indirect and direct laryngoscopy at admission revealed a round and smooth submucosal mass in the postcricoid region.

DIAGNOSIS

A laryngeal enhanced computed tomography and laryngoscopy suggested that the tumor located in hypopharynx, with clear boundary and slightly strengthened edge. A supporting laryngoscopy surgery was performed under general anesthesia and a biopsy confirmed solitary neurofibroma of the postcricoid region.

INTERVENTIONS

The tumor was successfully resected en bloc transorally through supporting laryngoscope, and obviated the need for open cervical surgery and tracheostomy.

OUTCOMES

The patient recovered well without any intraoperative or postoperative complication and was discharged from hospital 2 days after surgery. There was no recurrence after 6 months follow-up.

LESSONS

Postcricoid neurofibroma is an extremely rare hypopharynx tumor that can be diagnostically challenging. To the best of our knowledge, this is the first case reported of solitary neurofibroma originating from the postcricoid region of the hypopharynx and was surgically removed with transoral surgery through supporting laryngoscope.

Postcricoid vascular abnormalities: hemangiomas, venous malformations, or anatomic variant

OBJECTIVE

Ten children with pressure-dependent postcricoid masses (PDPCM) previously referred to in the literature as hemangiomas or vascular malformations are presented. We propose these lesions represent an anatomic variant. We review previously reported cases, and report the presentation, diagnosis, and management of the patients in our series, the largest series to date.

METHODS

Ten patients, aged five weeks to nine months, were diagnosed, and treated or observed. Of the patients undergoing intervention, one was treated with a gastrostomy tube, fundoplication, and Propranolol therapy; and the other with CHARGE association underwent a tracheotomy.

RESULTS

No PDPCMs demonstrated significant interval change in size or appearance, and eight of ten patients did well with observation.

CONCLUSION

Based on current information, the majority of PDPCMs likely represent an anatomic variant rather than a hemangioma or vascular malformation. Diagnosis is most readily made with awake flexible fiberoptic laryngoscopy. Because the incidence of synchronous airway pathology is high, direct laryngoscopy and bronchoscopy without routine biopsy is recommended for symptomatic patients. Imaging should be individualized and may be helpful for ambiguous cases. Although numerous treatment modalities have been advocated based on the presumptive diagnosis of a hemangioma, treatment of PDPCMs is not necessary in the majority of cases, as most patients may be safely observed.