Laser therapy for lymphatic malformations of the upper aerodigestive tract. An evolving experience

Conservative treatment of Head and Neck hemangiomas using Intralesional Bleomycin

Background

Hemangiomas are vascular tumours and commonly occur in head and neck region. Complete treatment of these vascular swellings are often challenging. As surgical excision carries high risk of complications and poor cosmetic outcome, treatment is shifted more towards non-surgical modalities like steroid therapy, radiotherapy, chemotherapy and sclerotherapy.

Objective

To study the efficacy of intralesional Bleomycin sclerotherapy for head and neck hemangiomas.

Method

Seventeen patients ( 9 males and 8 females) with head and neck hemangiomas were treated with sclerotherapy using intralesional bleomycin injection ( 0.1-0.5 mg/kg/ dose) in a medical college of India. Details of the patients were recorded along with serial photographs of lesion. Post injection outcomes in form of reduction of lesion size, patient satisfaction and complications were also recorded.

Results

11 patients were completely cured, 3 had more than 50% reduction in size, one patient showed minimal reduction and two had no response. One patient had superficial ulceration, one case of slough and fever was reported. None of the patients developed severe toxic side effects and pulmonary fibrosis with follow up of 18 months.

Conclusions

Bleomycin injection is safe, easy and well tolerated method for treatment of head and neck hemangiomas. We recommend surgery only if there is no response to other conservative treatment modalities.

Lymphatic and Mixed Malformations

Lymphatic and mixed malformations are rare and variable in presentation. They arise due to errors in vascular and lymphatic formation during early embryonic development. This leads to persistent infiltration of lymph fluid into soft tissues and causes a locally invasive mass with pathologic sequelae. Departing from historically descriptive terminology, such as "cystic hygroma," lymphatic malformations are now categorized as macrocystic, microcystic, or mixed lesions, based on size. Advances in imaging modalities, such as ultrasonography and magnetic resonance imaging, have made accurate characterization of these lesions possible and ultimately allow for early diagnosis and implementation of appropriate treatment based on the morphology of the lymphatic malformation. Management of lymphatic malformations can be quite challenging, and a multidisciplinary approach is most effective for optimum aesthetic and functional outcomes. New discoveries in the molecular biology of lymphatic malformations have provided treatment targets and established a role for pharmacotherapy. Sclerotherapy, laser, and radiofrequency ablation have all proven to be effective as minimally invasive treatment options for lymphatic malformations. Surgical intervention has a role in the treatment of focal lesions recalcitrant to these less invasive techniques. Operative planning is dictated by clinical goals, size, anatomic location, characteristics, and extent of infiltration.

Percutaneous sclerotherapy in neonatal and infant head and neck lymphatic malformations: a single center experience

PURPOSE

To evaluate the clinical outcomes of percutaneous sclerotherapy for congenital head and neck lymphatic malformations in our institution.

MATERIALS AND METHODS

Over a 7-year period, 17 children (10 M, 7 F) mean age 5.8 months (5 days to 13 months) underwent 49 sclerotherapy procedures for congenital head and neck malformations. The imaging and clinical records were reviewed for each patient. Ten of 17 had macrocystic disease; 7 of 17 had microcystic disease. Imaging response was categorized by volume reductions of 0% to 25%, 25% to 50%, 50% to 75%, or 75% to 100%. A concentration of 10 mg/mL doxycycline was used routinely via catheter in 3 instillations with a dose range of 50 to 500 mg per session as per our standard protocol in 17 of 17 patients. In more recent patients, systemic doxycycline levels were obtained after instillations. Additional treatments included direct injection doxycycline (10/17), instillation of absolute ethanol (7/17) or sodium tetradecyl sulfate (4/17), or a combination of these methods.

RESULTS

Imaging improvement of ≥ 76% was noted in 11 of 17. Of these, 8 of 11 had macrocystic disease. Four of 17 had 51% to 75% resolution, of which 3/4 were mixed. Two of 17 children had 25% to 50% resolution with a mixed lesion. Seven of 49 peri-procedural complications: hemolytic anemia in 2 infants, hypoglycemic and metabolic acidosis in 3 neonates aged 7 to 10 days, transient hypotension during absolute alcohol instillation in 1 neonate, and self-limiting skin excoriation secondary to peri-catheter leakage of doxycycline in one neonate. Neonates prone to these systemic complications had doxycycline doses of greater than 250 mg and resulted in serum levels of >5 μg/mL but as high as 21 μg/mL. Delayed neural complications occurred in 7 of 49 procedures, Horner's syndromes in 4 of 49 procedures, transient left lip weakness in 1 of 49 procedures, right facial nerve palsy in 1 of 49 procedures, and transient left hemidiaphragm paralysis in 1/49 procedures.

CONCLUSION

Our experience with catheter directed doxycycline sclerotherapy provides excellent results for large macrocystic head and neck lymphatic malformations. Microcystic and mixed lesions continue to provide a therapeutic challenge.

CO2 laser resurfacing of intraoral lymphatic malformations: a 10-year experience

OBJECTIVE

To evaluate the safety and efficacy of CO(2) laser resurfacing in the symptomatic treatment of intraoral lymphatic malformations (LM).

DESIGN

Retrospective review.

METHODS

Charts were reviewed on 26 patients (16 male, 10 female) from January 1997 to July 2007 who underwent CO(2) laser resurfacing for symptomatic treatment of intraoral LM. A questionnaire was given in order to elucidate effectiveness in controlling symptoms and speed of postoperative recovery.

RESULTS

Mean age at time of first treatment was 9.2 years (median 6.8). Mean number of treatments was 3.0 (median 2.5). Average time between treatments was 9.7 months (median 5.6). Questionnaires were returned for 17 patients (65%). Common preoperative symptoms included swelling, bleeding, vesicle formation, and pain. All 17 patients reported symptomatic improvement after laser treatment. Five patients (29%) tolerated oral intake immediately, 10 (59%) the following day, and 1 (6%) was gastric tube dependent. Four patients (24%) returned to normal activity immediately after treatments, six (35%) by the following day, six (35%) within a few days, and one (6%) within a week. No postoperative complications were seen.

CONCLUSION

CO(2) laser resurfacing appears to be both safe and efficacious in treatment of symptoms related to intraoral LM. Intermittent treatments for recurrent symptoms is expected.

Occult supraglottic lymphatic malformation presenting as obstructive sleep apnea

Sleep disordered breathing and obstructive sleep apnea is commonly encountered in the pediatric population. In many cases, it is the result of oropharyngeal obstruction secondary to adenoidal or adenotonsillar hypertrophy. We describe an unusual case of a child with adenoidal hypertrophy who had an occult supraglottic lymphatic malformation that manifested as obstructive sleep apnea. The management of this lesion is discussed including the use of endoscopy, carbon-dioxide laser, and the decision to avoid a tracheotomy. Occult supraglottic lymphatic malformations (LMs) are a rare cause of obstructive sleep apnea, the diagnosis of which will be missed without fiberoptic laryngeal examination. They are challenging to manage because of the airway involvement and propensity to recur.

A unique case of the rapid onset of a large cystic hygroma in the adult

Cystic hygroma is an uncommon lymphatic tumor seen rarely in adults, with less than 100 cases reported in the literature. The etiology and pathophysiology of this lesion is still in question. The majority of cystic hygromas occur in the head and neck, particularly in the posterior triangle. Although cystic hygromas tend to enlarge progressively over a span of weeks or months, relatively rapid enlargement over a span of days has been described. We present the unique case of an adult woman who experienced sudden onset of a large cystic hygroma in the neck without history of antecedent swelling, infection, or trauma. Successful surgical removal of the hygroma was performed. A brief review of the literature is presented.

Comparison of a high power diode laser with the Nd:YAG laser using in situ wound strength analysis of healing cutaneous incisions

BACKGROUND AND OBJECTIVE

The laser-tissue interaction of a high power semiconductor diode laser was compared to the continuous wave neodymium yttrium aluminum garnet (Nd:YAG) laser by evaluating primary wound healing of cutaneous incisions in rats.

STUDY DESIGN/MATERIALS AND METHODS

Full thickness incisions were made in rat skin using a diode laser (805 nm, 10 W, contact mode), an Nd:YAG laser (1,064 nm, 10 W, contact mode), and a stainless steel scalpel blade (control). In situ wound breaking strength measurements were obtained at 7, 14, and 21 days using a specially designed tensiometer. Cross sectional area of non-disrupted wounds was calculated in two groups prior to testing to allow for calculation of tensile strength. Blinded histopathologic analysis was also performed.

RESULTS

Analysis of variance (P < or = 0.05) was used to determine differences in breaking strengths and tensile strengths due to incision method. There was no significant difference in the breaking strengths (group 1) or tensile strengths (groups 2 and 3) of the diode and Nd:YAG laser incisions. As predicted, breaking strengths and tensile strengths of scalpel blade incisions were significantly greater than those of incisions made with laser energy. Histopathologic evaluation revealed that through day 14, the degree of inflammation and collagen production was similar for diode and Nd:YAG laser incisions. Laser incisions had greater inflammation and a lag in fibroblast invasion and collagen production compared with scalpel incisions. By day 21, all incisions were similar in fibroblast population and collagen production, but laser incisions had slightly more inflammation than scalpel incisions.

CONCLUSION

In the primary wound healing model described, the tissue effect, cellular response, and development of wound strength were essentially the same for the high power diode laser at 10 W and the Nd:YAG laser at 10 W.

Bleomycin sclerotherapy in patients with congenital lymphatic malformation in the head and neck

Congenital lymphatic malformations of the head and neck often present challenging problems to the otolaryngologist-head and neck surgeon. Although surgical excision was agreed to be the treatment of choice for this disease, the infiltrating nature of lymphatic channels often increases the frequency of operative complications and recurrences of this lesion.

PURPOSE

Bleomycin sclerotherapy was attempted to avoid surgical risk and to cure this lesion.

MATERIALS AND METHODS

Clinical findings and treatment results were reviewed for patients with congenital lymphatic malformation and treated by bleomycin sclerotherapy.

RESULTS

Bleomycin sclerotherapy was a very effective therapeutic alternative. The best results were seen in cystic type 1 lesions in younger patients.

CONCLUSIONS

Bleomycin sclerotherapy is a useful medical alternative, and we believe that it should be attempted before excision of the lesion.

Clinical applications of lasers in otolaryngology--head and neck surgery

The use of lasers in otolaryngology--head and neck surgery is described from the invention of the laser in 1960, through the current uses of the laser, and concludes with a summary for the future directions of laser surgery. The various lasers, including the argon, the KTP, and the carbon dioxide lasers used in otolaryngology, are briefly described. The applications of lasers in the larynx, sinuses, and the ear are separately covered, as well as pediatric otolaryngology. In addition to a brief description of the procedure, the complications and limitations are given. Anesthetic considerations are also covered.