Infantile hemangioma: treatment with surgery or steroids

Classification and Pathology of Congenital and Perinatal Vascular Anomalies of the Head and Neck

Accurate histopathologic description in correlation with clinical and radiological evaluation is required for treatment of vascular anomalies, both neoplastic and malformative. It is important to examine current clinical, histologic, and immunophenotypical features that distinguish the major types of congenital and perinatal vascular anomalies affecting the head and neck. General discussions of pathogenesis and molecular diagnosis must also be taken into account. This article provides an overview of the features that distinguish the major types of congenital and perinatal vascular anomalies affecting the head and neck, and summarizes the diagnostic histopathologic criteria and nomenclature currently applied to these lesions.

Infantile haemangioma

With a prevalence of 4·5%, infantile haemangiomas are the most common benign tumours of infancy, arising in the first few weeks of life and exhibiting a characteristic sequence of growth and spontaneous involution. Most infantile haemangiomas do not require therapy. However, to identify at-risk haemangiomas, close follow-up is crucial in the first weeks of life; 80% of all haemangiomas reach their final size by 3 months of age. The main indications for treatment are life-threatening infantile haemangioma (causing heart failure or respiratory distress), tumours posing functional risks (eg, visual obstruction, amblyopia, or feeding difficulties), ulceration, and severe anatomic distortion, especially on the face. Oral propranolol is now the first-line treatment, which should be administered as early as possible to avoid potential complications. Haemangioma shrinkage is rapidly observed with oral propranolol, but a minimum of 6 months of therapy is recommended.

Hemangiomas and the eye

Infantile hemangiomas are a common vascular birthmark with heterogeneous presentations and unique growth characteristics with early rapid growth and eventual self-involution. Hemangiomas that develop around the eye have the potential for inducing amblyopia by several mechanisms and may eventually result in permanent visual impairment in otherwise healthy infants. Segmental periocular hemangiomas carry the additional risk of associated structural anomalies and PHACE syndrome. In recent years, the treatment of periocular hemangiomas has been revolutionized by the serendipitous discovery of the effectiveness of beta-blockers (systemic and topical), with most experts viewing these as first-line therapies. The management of periocular hemangiomas should involve a close partnership between an ophthalmologist and dermatologist or other relevant specialists familiar with the unique clinical features, differential diagnosis, treatment approaches, and potential complications.

Multicenter Evaluation of the Effectiveness of Systemic Propranolol in the Treatment of Airway Hemangiomas

Objective

To evaluate the effectiveness of systemic propranolol in airway infantile hemangioma (AIH) treatment.

Design

Case series with chart review.

Participants

Patients with AIH treated with propranolol between 2009 and 2012 with at least a 1-year follow-up.

Outcomes

Presenting age, treating institution, syndrome presence, presenting AIH stage, endoscopy status, propranolol initiation location/dose/duration, time to stridor resolution, adjunctive medical and surgical therapy, and treatment-associated complications.

Results

Twenty-seven patients met inclusion criteria. Average age of diagnosis was 2.3 months (range, 1-5 months). The AIHs were stage 1 in 7 of 27 (26%), stage 2 in 12 of 27 (44%), and stage 3 in 8 of 27 (30%). Propranolol initiation was inpatient in 25 of 27 (93%) and outpatient in 2 of 27 (7%). Propranolol dose was maintained at 2 mg/kg/d in all patients for a minimum of 7 months (range, 7-34 months; median, 15 months). Stridor was eliminated within 24 hours or less of propranolol initiation in 23 of 27 (85%). At diagnosis, staging and propranolol initiation in 11 of 27 (41%) were managed with propranolol alone; the remaining 16 of 27 (59%) also had a steroid injection. The use of adjuvant therapy at the time of propranolol initiation and the size of the AIH were not statistically correlated. Twelve patients had additional treatments after the initiation of propranolol due to recurrence of respiratory symptoms, 1 of 27 (4%) of whom was considered a nonresponder. No complications related to propranolol use were noted.

Conclusions

This multisite study of AIH treatment with propranolol demonstrates similar effectiveness to surgical treatment modalities. Propranolol therapy for AIH had no complications, had potentially lower resource utilization, and should be considered a first-line AIH treatment.

Neck masses in paediatric population: An experience with children attended the Central Teaching Hospital of Pediatrics in Baghdad 2008-2009

BACKGROUND

Pediatric neck mass is a frequent cause for surgical consultation. Neck masses can be simply classified into congenital, inflammatory, and neoplastic. Although most of the cases are due to benign processes, malignant causes must not be overlooked. The aim of this study is to assess the paediatric neck masses in Iraqi patients highlighting the distribution of cases according to their demographic characteristics and etiology.

PATIENTS AND METHODS

A cross-sectional observed study is conducted in the Department of Pediatric Surgery, at the Central Teaching Hospital of Pediatrics in Baghdad from April 2008 to March 2009. Sixty four patients with neck masses aged 14 years and below were examined and managed. The underlying causes of the neck masses were addressed and categorized.

RESULTS

Among the 64 patients, 42 (65.6%) were male. The inflammatory group represents 57% of the cases, while the malignant neoplasm accounts for approximately 10% of the conditions mainly due to lymphoma 5 (7.8%). Sixteen patients (25%) fall in the congenital group, in which the thyroglossal duct cyst was the commonest type. Wound infection developed in two patients, while one patient with cystic hygroma showed recurrence.

CONCLUSION

Pediatrics neck masses are distributed in categories that similar in pattern and distribution in the world except the infectious/inflammatory category that shows variation in distribution in respect to the socioeconomic status. The surgical intervention and procedures are related to the facility as well as to the experience.

Infantile Hemangioma: A Brief Review

Infantile hemangiomas as frequent infancy tumors have been a controversial issue of medical scientists worldwide. Their clinical aspects are various and their physiopathology is yet to be fully understood. Numerous publications outline the characteristics, causes, evolution possibilities and therapeutic approaches. Deciding whether to treat or not is the main question of this kind of pathology. Hemangiomas that have complications or can cause irreversible damage need therapy. This is a brief review of up-to-date information regarding the presentation of infantile hemangiomas and target-therapies.

Propranolol and central nervous system function: potential implications for paediatric patients with infantile haemangiomas

Given its improved safety profile compared with systemic corticosteroids, propranolol has become the mainstay treatment of infantile haemangioma (IH) worldwide. There is evidence, mainly from adult volunteer studies, that propranolol use is associated with central nervous system (CNS) effects. Impairment to short- and long-term memory, psychomotor function, sleep quality and mood with relatively low doses and durations of treatment have been reported. The exact magnitude of CNS effects resulting from propranolol use, especially in the early developmental stages and for prolonged periods of use, is not currently known. These effects may not be readily recognizable and require specialized assessment of cognitive function not routinely performed. Furthermore, there may be a delay between exposure and cognitive defects. The evidence to date provides a strong rationale to proceed with caution when prescribing propranolol for IH: treatment should be used only when indicated (in the presence of ulceration, impairment of a vital function or risk of permanent disfigurement) and for a limited duration, and the benefits of treatment should be weighed carefully against potential adverse events before treatment is initiated. This narrative review describes the evidence for an effect of propranolol use on CNS function from volunteer and patient studies, including IH.