Congenital laryngeal hemangioma

The Treatment of Adult Laryngeal Hemangiomas Located on the Arytenoids: Excision vs. Chemotherapy

OBJECTIVE

To evaluate and compare the results of the excision and bleomycin injection treatment methods for adult laryngeal hemangiomas (ALHs) located on the arytenoids.

METHODS

Twenty-six ALH patients in 29 different cases were enrolled in the study at our department between June 2012 and March 2021. Some patients were treated more than once. Twenty-nine cases of ALH treated with either bleomycin injection or excision were studied to assess the efficacy of both treatments. A lumen constriction score (from 1 to 4) was used to evaluate the therapeutic effect three months later.

RESULTS

The ALHs in the ALH excision group were resected successfully, and the ALHs did not recur. The mean lumen constriction score for the bleomycin injection group was 2.95. The lumen constriction score for the ALH excision group was higher than that of the bleomycin injection group.

CONCLUSIONS

Both bleomycin injection and excision are safe and effective treatments for ALHs located on the arytenoids. On the condition that the ALH is well exposed and can be completely removed, ALH excision surgery is the preferable method to treat ALHs located on the arytenoids.

Suprahyoid pharyngotomy for excision of laryngeal venous malformation

We report an uncommon case of symptomatic venous malformation of the larynx in a 22-year-old man, and the successful surgical management thereof. A detailed radiologic investigation of the lesion was done, followed by surgical excision via a suprahyoid pharyngotomy using cold instruments. Long-term follow-up was maintained, and the patient had subjective and objective resolution of his symptoms and signs at 3 years postoperatively. We conclude that radiology can reveal hitherto unsuspected extensions of vascular malformations in the neck and that surgical excision is a viable mode of treatment in upper aerodigestive venous malformations.

Airway procedures and hemangiomas: treatment patterns and outcome in U.S. pediatric hospitals

OBJECTIVE

Characterize and compare care in children with hemangiomas, who do or do not undergo airway procedures.

METHODS

National retrospective cohort study of patients aged 0-18 with hemangiomas, from 33 freestanding United States pediatric hospital discharge records, 2001-2005. The main outcome measures were therapy, readmission and mortality.

RESULTS

Of 2890 patients diagnosed with hemangiomas, 337 (12%) underwent airway procedures. Most airway procedures were for patients between ages 1 and 11 months. Patients with hemangiomas and airway procedures had more steroid use (80%), increased readmission (30%), and increased mortality (2%) compared to hemangioma patients without airway procedures. Procedures (i.e. laser, open surgery, tracheotomy) and age over 4 months in airway procedure patients were associated with decreased readmission. Increased readmissions were associated with systemic steroid administration.

CONCLUSION

Hemangioma patients who undergo airway procedures experience increased medical and surgical therapy compared to those who do not. Readmission is increased in patients with hemangiomas and airway procedures, but surgical intervention and age greater than 4 months decreased readmission.

CT of hemangiomas of the upper airways in children

OBJECTIVE

Hemangiomas of the airways in infants are commonly diagnosed at bronchoscopy performed for the investigation of stridor or other respiratory symptoms. Occasionally on bronchoscopy the appearances are atypical or the entire extent of the suspected hemangioma cannot be appreciated. We report on the clinical usefulness of dynamic contrast-enhanced CT in the evaluation of suspected hemangiomas of the airways in infants. CT findings of 11 infants who underwent investigation for a suspected airway hemangioma were correlated with bronchoscopic findings.

CONCLUSION

Dynamic contrast-enhanced CT is a valuable noninvasive method for the evaluation of airway hemangiomas. Although it can be used to confirm the diagnosis in patients with equivocal findings on bronchoscopy, we believe that CT findings are specific enough that CT can be recommended as the primary method of establishing the diagnosis. Multiplanar reconstructions illustrate the location, extent, and degree of luminal narrowing and any involvement of adjacent tissues.

The biology and management of subglottic hemangioma: past, present, future

OBJECTIVES/HYPOTHESIS

Objectives were 1) to review the presentation, natural history, and management of subglottic hemangioma; 2) to assess the affect of five variables (age, gender, degree of subglottic narrowing, location and extent of subglottic hemangioma, and lack or presence of other hemangioma) and the outcome of six different treatment modalities (conservative monitoring, corticosteroid, laser surgery, tracheotomy, laryngotracheoplasty, and interferon) in the management of subglottic hemangioma; and 3) to present specific guidelines to help determine the best possible treatment modality at the time of initial presentation.

STUDY DESIGN

Retrospective review in the setting of three tertiary care pediatric medical centers.

METHODS

Methods included 1) extensive review of the literature; 2) a systematic review with respect to age, gender, presentation, associated medical problems, location and degree of subglottic narrowing, initial treatment, need for subsequent treatments, outcome, complications, and prognosis; and 3) statistical analysis to determine the effect of five variables (age, gender, degree of subglottic narrowing, location and extent of subglottic hemangioma, and lack or presence of other hemangioma) and the outcome of six different treatment modalities (conservative monitoring, corticosteroid, laser surgery, tracheotomy, laryngotracheoplasty, and interferon).

RESULTS

In all, 116 patients with a mean age of 4.7 months were treated. The most common location of subglottic hemangioma was the left side. The range of subglottic narrowing was 10% to 99% (mean percentage, 65%). Twenty-six patients (22%) were managed with a single treatment modality, which included conservative monitoring (n = 13), corticosteroid (n = 11), and tracheotomy (n = 2). Ninety patients (78%) required multimodality treatments. Overall, the treatments included conservative monitoring (n = 13), corticosteroid (n = 100), tracheotomy (n = 32), CO2 laser (n = 66), interferon (n = 5), and laryngotracheoplasty (n = 25). Complication rates included the following: conservative monitoring (none), corticosteroid (18%), tracheotomy (none), CO2 laser (12%), interferon (20%), and laryngotracheoplasty (20%). The following variables showed statistical significance in the outcome of different treatment modality: 1) degree of subglottic narrowing (P < .001), 2) location of subglottic hemangioma (P < .01), and 3) presence of hemangioma in other areas (P < .005). Gender (P > .05) and age at the time of presentation (P > .06) did not show any statistical significance on the outcome of the treatments.

CONCLUSION

Each patient should be assessed comprehensively, and treatment should be individualized based on symptoms, clinical findings, and experience of the surgeon. The authors presented treatment guidelines in an attempt to rationalize the management of subglottic hemangioma and to help determine the best possible treatment modality at the time of initial presentation.

Six cases of children with a benign cervical tumor who required tracheostomy

Cervical tumors sometimes cause airway obstruction. We have treated six children with benign cervical tumors who required tracheostomy. Two cervical and one glossal lymphangiomata treated with local injection of OK432 after creating a tracheostomy were successfully decannulated after the treatment. One patient with a giant cervical lymphangioma needed an EXIT (ex utero intrapartum treatment) procedure. He underwent tracheostomy at 10 months of age after long-term endotracheal intubation, but he died of sepsis and hypoxic brain damage at 18 months. One patient with a subglottic hemangioma treated with steroids finally achieved closure of the tracheostomy at 2 years of age. A 7-year-old girl with a tracheal schwannoma underwent tracheostomy performed a week after admission, but she already had hypoxic brain damage resulting from problems with intubation. Most patients with a lymphangioma or hemangioma in the cervical region have required early tracheostomy before commencing treatment with OK-432 or steroids. If there is any sign of possible airway compromise, then it is vital to perform an early tracheostomy, even for benign tumors.

Laser surgery: new applications for pediatric skin and airway lesions

Recent research pertaining to laser applications for the treatment of capillary malformations (port wine stains) and cutaneous and subglottic hemangiomas is reviewed within the context of advances in laser technology and current therapeutic practices and controversies. Although laser advances have resulted in the concomitant growth of new clinical applications, research over the past year has focused on refining and improving existing applications, with the ultimate goal of being able to individualize treatment. Research initiatives aimed at improving the outcomes of pulse dye laser treatment for capillary malformations have illustrated the complexity of the interaction between laser characteristics, methods of laser application, variations in human skin and tissue, and morphologic parameters of involved blood vessels. Investigations of cutaneous hemangioma have addressed the issue of early pulse dye laser intervention, and results of a significant prospective study clearly demonstrate that this offers no benefit. Studies of subglottic hemangioma have compared the outcomes of treatment with carbon dioxide (CO(2)) and the potassium-titanyl-phosphate lasers, concluding that the latter results in superior outcomes, with less risk of posttreatment subglottic stenosis.

A review of the current management of infantile subglottic haemangioma, including a comparison of CO(2) laser therapy versus tracheostomy

OBJECTIVES

We reassessed the current practice and treatment options used in the management of subglottic haemangiomas (SGHs), including the place for open submucosal surgical excision, and have compared the results of different therapeutic modalities used for SGHs.

METHODS

The two studies were conducted as separate exercises; (1) a retrospective review of 36 patients collected over a recent 8-year period to assess the current practice and treatment options in use; (2) a retrospective comparative study of a previous cohort of 51 patients with SGHs treated in one of four groups: (a) tracheostomy alone, (b) tracheostomy and CO(2) laser, (c) systemic steroids and CO(2) laser (no tracheostomy) and (d) intralesional steroid injection, CO(2) laser therapy, or both, followed by intubation.

RESULTS

Systemic steroids were the most commonly used modality of treatment. Resolution of the SGH was achieved in 89% of cases at a mean follow up duration of 34 months. However, tracheostomy was required in 58% of cases, with a mean time from diagnosis to decannulation of 30 months. The time to resolution of SGHs does not appear to be reduced by laser therapy compared with treatment by tracheostomy alone. Intralesional steroid injection or laser therapy together with intubation was associated with avoidance of a tracheostomy in 66% of cases. Single-stage open surgical excision in two cases resulted in successful resolution of the SGH and discharge after a mean follow up period of 3 months.

CONCLUSIONS

Despite the more widespread use of steroids and other treatment modalities, the requirement for tracheostomy has remained unchanged over the last 20 years. The use of laser therapy does not appear to confer any additional therapeutic benefit over and above tracheostomy alone in bringing about resolution of SGHs. Systemic steroids may reduce the size of the haemangioma but are associated with multiple adverse effects. The decision to use the above techniques must, therefore, be made in the light of these observations. Our early experience of single-stage excision suggests that this technique represents an exciting and promising surgical alternative, and its more widespread adoption may be the only way of further improving the outcome of patients with SGHs.

Use of potassium titanyl phosphate (KTP) laser in management of subglottic hemangiomas

OBJECTIVE

to study the role of KTP laser in management of subglottic hemangioma.

DESIGN

retrospective analysis of patients with subglottic hemangioma treated by the senior authors.

SETTING

tertiary care teaching hospital.

PATIENTS

twelve patients with subglottic hemangiomas.

INTERVENTION

patients were treated with KTP laser (eight cases), CO(2) laser (two cases) or observation (two cases).

MAIN OUTCOME MEASURE

resolution of symptoms, decrease in size of subglottic hemangioma or tracheotomy decannulation.

RESULTS

All patients treated with KTP laser or CO(2) laser had resolution of symptoms and five tracheotomy-dependent children were decannulated.

CONCLUSION

subglottic hemangioma is a potentially life-threatening disease seen in young children. Most authors recommend use of either CO(2) or open surgical excision. There is very little data available on the use of KTP lasers in the management of subglottic hemangiomas. The KTP laser beam is preferentially absorbed by hemoglobin making this laser system more applicable to the treatment of vascular tumors such as the hemangioma. KTP laser is a good tool for management of subglottic hemangioma with a low incidence of complications.

Treatment of 'angiomas': a modern commentary

The terminology and classification of vascular birthmarks has been simplified and clarified since 1951. Where treatment is indicated, this also has changed from radiotherapy being the treatment of choice to now having a range of therapeutic options including corticosteroids, alpha-interferon, alginate and hydrocolloid dressings, antibiotics, laser and surgery. Another important aspect of the management of haemangiomas is the recognition that certain patterns can be associated with other abnormalities.

Laser treatment of hemangiomas of the larynx and trachea

BACKGROUND AND OBJECTIVE

Hemangiomas have a typical clinical course and may lead to life-threatening obstruction if the central respiratory tract is involved.

STUDY DESIGN/PATIENTS AND METHODS

This was observed in 32 children over a period of 20 years. The radiation parameters and application procedure of Neodymium:Yttrium-Aluminum-Garnet-laser (Nd:YAG-laser) therapy were adjusted for the degree of obstruction and the type of disease.

RESULTS

The success rate was 93.8%, of which a maximum of one application was sufficient in 24 children (75.0%). Subglottic cicatricial stenosis was considered a laser-related complication.

CONCLUSION

Nd:YAG-laser treatment is a safe and effective therapeutic measure for eliminating respiratory tract obstruction caused by hemangiomas.

Management of infantile subglottic hemangioma: laser vaporization, submucous resection, intubation, or intralesional steroids?

The infantile subglottic hemangioma can be treated in various ways. The results of the treatment used in the Sophia Children's Hospital, intralesional steroids and intubation (IS + I), are discussed and compared with the results of other current treatment methods: CO2 laser vaporization, submucous resection and intubation alone. A total of 18 infants were treated for subglottic hemangioma in our hospital: ten with IS + I alone, five were first treated with systemic therapy and later with IS + I alone and three with various therapies. IS + I was effective in 14 of the 15 patients, one patient was lost from follow up. The remaining three infants were treated with (combinations of) various therapies, because IS + I failed or was not tried. Two patients were finally cured, one still has a tracheotomy. Of other current therapies, CO2 laser vaporization is reported to be effective. In all 30% of the infants treated in Boston Children's Hospital with CO2 laser needed a tracheotomy. Moreover subglottic stenosis is a serious complication. Submucous resection is often successful. It may be complicated by subglottic stenosis and in some cases, depending on the localization of the hemangioma, it may be contraindicated. Intubation alone is less effective than intubation combined with intralesional steroids. Management of subglottic hemangioma in Sophia Children's Hospital is primarily intralesional steroids and intubation and secondarily submucous resection or tracheotomy. CO2 laser vaporization is seldom applied because of the risk of subglottic stenosis.

Contrasting strategic approaches to the management of subglottic hemangiomas

The standards of treatment of subglottic hemangiomas are steroids and laser vaporization. If these methods do not provide a sufficient airway, a tracheotomy may be required. Analysis of the data available in the literature shows that there is a place for other therapeutic solutions. Open surgical excision could be one of them but is controversial. So far, it represented a 'last' resort procedure before tracheotomy. Our approach to open surgical excision is different. A prospective decision is taken in the initial therapeutic approach. Infants are considered candidates for excision in cases of large hemangiomas that extend beyond the limits of laser. Laser is, then, avoided in order not to damage the overlying mucosa. Interferon is not utilized because a rapid effect is not expected on the respiratory distress. Open surgical excision without tracheotomy is performed. A cricoid enlargement is associated at the end of the procedure. Risk for post-operative subglottic stenosis is limited. When conceived this way, open surgical excision seems effective to manage large life-threatening hemangiomas.

Interferon alfa-2a therapy for airway hemangiomas

Hemangioma is a well-recognized cause of airway obstruction in the infant with stridor. Corticosteroid and laser therapy are effective in stabilizing the airway in most cases. There are, however, some extensive airway lesions that are not adequately managed by these modalities. This report describes the use of recombinant interferon alfa-2a in 15 patients with life-threatening airway hemangiomas. All patients had failed corticosteroid and/or laser therapy. Multiple upper airway sites were involved, including the base of the tongue, supraglottis, subglottis, trachea, and mediastinum. Eleven patients have completed therapy and are doing well. Four patients have resolving lesions on the drug regimen. Life-threatening airway lesions unresponsive to conventional treatment should be considered for a trial of interferon alfa-2a.

Intraoral vascular malformation and airway management: a case report and review of the literature

A patient with a large airway venous malformation underwent anesthesia for a tooth extraction. The procedure was uneventful until extubation, immediately after which complete airway obstruction resulted. After unsuccessful attempts to relieve the problem, the patient's trachea was reintubated. Laryngoscopy showed that the venous malformation in the airway had enlarged and was responsible for the airway obstruction. Another attempt at extubation after corrective maneuvers was again unsuccessful. A tracheostomy was required, which was eventually removed after a complete recovery. Anesthesiologists must be concerned with any airway vascular abnormality. Most abnormalities involving the airway are either hemangiomas or venous malformations. The anesthesiologist must diagnose the problem correctly because even minor manipulation of a venous malformation may result in exsanguination, or the malformation may become engorged and compromise the airway.

Subglottic hemangiomas in infants: treatment with intralesional corticosteroid injection and intubation

Six children with a subglottic hemangioma were treated in the Sophia Children's Hospital in the period 1982-1987 by means of intralesional corticosteroid injection, followed by intubation. After treatment all children were symptomfree. In 3 patients this result was attained after 1 injection, in 2 after 3 injections. One patient needed 5 injections. The average duration of intubation was 19 days (7-36). Three months (1/2-7 1/2) after the onset of therapy all patients were free of symptoms. No serious complications were observed. No patient needed a tracheotomy. The average follow-up period was 3.3 years (1 1/2-5 1/2). The authors feel that not only the effect of intralesional corticosteroids, but also local gentle pressure by the tube is of therapeutic importance. The above-mentioned treatment of subglottic hemangioma in children is now the treatment of choice in our clinic.

Severe upper airway obstruction

This article describes management of newborn and older children with severe upper airway obstruction, that is, those needing or likely to need airway support for their intact survival. These children have more to gain from optimal care, and more to lose from any error than most other children requiring admission to a pediatric intensive care unit.

Posterior glottic pathology

In infants and children, pathology in the posterior glottis is usually congenital or acquired due to endotracheal intubation. Diagnostic errors and omissions are less likely to occur with an anaesthetic technique where no endotracheal tube is used, where the posterior commissure and arytenoids are deliberately separated by a laryngoscope and where movements of the vocal cords and arytenoids are carefully assessed.

Infantile subglottic hemangiomas. An update

Between 1913 and 1985, 323 cases of infantile subglottic hemangiomas have been reported in the English language literature. The purpose of this study is to review these cases, to report The Johns Hopkins Hospital experience with ten additional cases, and to compare the various methods of treatment in an attempt to identify the regimens associated with the best outcome. The majority of the patients presented before the age of 6 months with respiratory distress, most commonly inspiratory stridor. There was a 2:1 female to male preponderance. The diagnosis was established by endoscopy in the majority and confirmed by biopsy in one third, without serious bleeding complications. A plethora of treatment methods have been described, including the following: corticosteroids, tracheotomy, radiation therapy, radioactive implant therapy, surgical excision, cryotherapy, and carbon dioxide laser. These methods were reviewed and their results compared to our own. We conclude that several methods are effective, each having its advantages and disadvantages. We believe that immediate tracheotomy should be performed in cases with severe airway obstruction. Smaller lesions may be vaporized with the carbon dioxide laser without tracheotomy if postoperative care is provided in a pediatric intensive care unit. Corticosteroids may be used alone or in combination with other modalities. External radiation therapy and injection of sclerosing agents are not advised.

Laryngeal stenosis following carbon dioxide laser in subglottic hemangioma. Report of three cases

Recent reports recommend carbon dioxide laser as the safest and the most effective treatment for subglottic hemangioma in infants. Though one report mentions the development of a small amount of subglottic scarring in an 8-month-old girl after resection of a subglottic hemangioma, there is insufficient emphasis in the literature with respect to stenosis as a complication of CO2 laser therapy. The authors present three cases of severe laryngotracheal stenosis developing in infants treated with the CO2 laser for subglottic hemangioma. The presentation of these three cases should be a warning to the otolaryngologist that the use of the CO2 laser is not without significant risk of scar tissue formation.

Carbon dioxide laser in subglottic hemangioma. An update

Congenital subglottic hemangioma is a potentially life-threatening lesion which frequently presents before the age of 6 months. Many forms of therapy have been advocated for the treatment of this difficult lesion. The use of the carbon dioxide laser has been advocated in the past and this report represents an update in treating 31 patients from 1975 to 1983. The success rate was 94% and the complication rate was 6.5%. This form of therapy is an effective and valuable addition to those already available for this troublesome lesion.