[Interdisciplinary concept for classification and treatment of vascular anomalies in the head and neck]

Interdisciplinary Management of Head and Neck Vascular Anomalies: Clinical Presentation, Diagnostic Findings and Minimalinvasive Therapies

OBJECTIVES

Vascular anomalies are included in the 30 000 rare diseases worldwide affecting less than 5/10 000 people. Depending on their morphology and biological properties, they can cause varied disorders with organ involvement. Almost 60% of vascular anomalies have a predilection for the head and neck region in children. Clinical and scientific effort to establish interdisciplinary management concepts for vascular anomalies is increasing worldwide.

METHODS

Especially in the head and neck region, clinical impairment and organ dysfunction is associated with cosmetic issues that may represent a physical and psychological issue for the patient. Correct diagnosis, based on clinical presentation and symptoms, is a prerequisite for appropriate therapy, ranging from conservative management to a spectrum of minimally invasive treatment options. We searched PubMed for German and English language published data until December 2016 with focus on clinical studies, review articles and case reports on vascular anomalies with a focus on the head and neck region.

RESULTS

The last ISSVA update in 2014 has contributed to a better understanding of vascular anomalies, classifying them in vascular tumors and vascular malformations. The predominant representatives of vascular tumors are congenital and infantile hemangiomas. Infantile hemangiomas have the ability of spontaneous regression in more than 80%. Patients with symptomatic growing hemangiomas with ulcerations, bleeding complications and restriction of hearing, swallowing disorder, impairment of vision, or cosmetic dysfigurement require treatment. Therapies include oral propanolol, transcatheter embolization and surgery. Vascular malformations tend to progress with patientś age and are subdivided in slow flow and fast flow lesions. Symptomatic slow flow lesions, e.g. venous and lymphatic malformations, benefit from percutaneous sclerotherapy. Fast flow lesions, as arteriovenous malformations, are rare but undoubtedly therapeutically the most challenging vascular anomaly. Depending on location and size, they may require multiple transcatheter embolization procedures for successful occlusion of the AVM.

CONCLUSIONS

This review provides knowledge on the current ISSVA classification of vascular anomalies, their clinical presentation, diagnostic evaluation and minimally invasive therapy options to encourage the establishment of a comprehensive interdisciplinary management for head and neck vascular anomalies.

[Recurrent epistaxis of unknown origin. A rare differential diagnosis and its treatment]

We present the case report on a 66-year-old male patient who appeared in our clinic with recurrent epistaxis. Anterior rhinoscopy during acute bleeding yielded no information on the origin of hemorrhage. On renewed epistaxis, angiography was performed on which an arteriovenous malformation in the sphenoid sinus could be identified as the cause of epistaxis. Embolization of afferent vessels successfully reduced the malformation and stopped the bleeding. In cases of recurrent epistaxis, especially in combination with an unremarkable anterior rhinoscopy, angiography is recommended for the detection of life-threatening vessel malformations.

Current concepts in the classification, diagnosis and treatment of vascular anomalies

Patients with extended vascular anomalies may suffer from significant aesthetic and functional impairment and represent a challenge to therapeutic planning, which is best met by an interdisciplinary concept. In agreement with the International Society for the Study of Vascular Anomalies (ISSVA), vascular lesions are classified into haemangiomas as proliferating endothelial tumours on the one hand and congenital vascular malformations on the other. According to the preponderant vascular channels and hemodynamic characteristics, malformations are subdivided into low flow (venous, lymphatic and capillary) lesions and high-flow malformations. Diagnostic imaging should be targeted at the specific structural and functional informations required for treatment planning. The imaging modality of choice to provide these informations is magnetic resonance imaging (MRI) supplemented by magnetic resonance angiography (MRA) with high spatial and temporal resolution. Treatment indications for haemangiomas depend on the proliferative behaviour of the lesion and comprise beta-blockers in order to induce involution as well as cryotherapy, laser and open surgery. Interventional radiological procedures have evolved as an essential element in an interdisciplinary treatment plan for vascular malformations and include percutaneous sclerotherapy with ethanol and OK-432 for venous and lymphatic malformations and transarterial embolization for high-flow lesions.

Manifestation einer arteriovenösen Malformation nach Zahnextraktion

CASE REPORT

We report on the case of a 31-year old female presenting a massive bleeding during extraction of left lower wisdom tooth, which could be managed by local compression. In the following transfemoral angiography an extensive arteriovenous malformation (avm) in the pterygomandibular space with osseous infiltration was diagnosed and embolised during the same session. After the acute stage the malformation could be controlled by repeated embolisation, the wound being closed by use of a transposition flap.

CONCLUSIONS

Although arteriovenous malformations of the head and neck are rare, they can manifest with dramatic bleeding complications during surgical interventions. A thrill on palpation and auscultation may also refer to the existence of such a vascular lesion. An av-malformation may be stimulated by hormonal changes during puberty or pregnancy as well as by local trauma. Colour coded duplex sonography, magnetic resonance imaging and transfemoral angiography are suitable diagnostic tools. The treatment of choice is superselective embolisation followed by surgical resection of the vascular nidus, which should be performed by under an interdisciplinary approach.

Laser Treatment of Venous Malformations

Venous malformations (VM) are developmental errors comprised of enlarged dysplastic blood vessels. Clinically they manifest as either a faint blue patch or a soft blue vascular mass. Treatment options include a sclerosing agent (such as alcohol or ethiblock), surgery or laser therapy. A review of the literature concerning VM and laser treatment yielded a few sporadic reports describing series of 3 to 46 cases. In this retrospective study we reviewed the files of the relevant cases. The data included the extent of the lesion, the different anatomical sites, age of patient and the extent of clearance of the lesion as the treatment's end point. This study includes 56 cases which makes it the largest series presented. The success rate of laser treatment was 92.8%. The immediate complication rate was very low (approximately 3.57%) including minimal scarring and deformity. No long term complications were noted. Our study concludes that treatment of VM is a difficult task due to the nature of the lesions. Laser treatment of these lesions enables one to obtain good results with a very low incidence of complications. Surgery and other treatment modalities are not always satisfactory, yield similar or less efficient results and have a higher complication rate. Laser treatment can play an important role in the treatment of VM and in fact may be the treatment of choice in some settings.

Percutaneous Ethanol Sclerotherapy for Vascular Malformations in the Head and Neck

Vascular malformations are frequent in the head and neck. In addition to the occasional devastating cosmetic effects of large vascular malformations, some may cause significant functional impairment by encroaching on the eye, tongue, or throat. Large lesions may produce a breakdown of skin or mucosa, with resultant leakage of blood or fluid and possible infection in the lesions and surrounding tissues. Arteriovenous malformations, in particular, may develop massive bleeding spontaneously or with minor trauma. Numerous treatment options are available for treatment of these lesions. Surgical excision is the traditional treatment for vascular malformations in the head and neck. However, some lesions may be difficult to remove when they permeate and envelop normal structures, such as the facial nerve, and a less invasive mode of therapy may prevent damage to these normal structures. Percutaneous sclerotherapy was developed as a minimally invasive treatment modality for these lesions. It has also proved helpful as a preoperative adjunctive treatment of these lesions to reduce surgical blood loss and to delineate the surgical extent of resection.