Propranolol for the treatment of subglottic hemangiomas

Diagnostic Techniques for Infantile Subglottic Hemangiomas: A Scoping Review

OBJECTIVE

Infantile subglottic hemangioma (SGH) poses a risk of airway compromise if untreated. Traditionally, operative endoscopy (OH) diagnoses SGH, but since the discovery of beta-blockers' efficacy in treating infantile hemangiomas (IHs) in 2008, and advances in endoscopic technology, nonoperative methods have emerged. This review identifies endoscopic practices for diagnosing and monitoring infantile SGH during the oral beta-blocker treatment era.

DATA SOURCES

A comprehensive literature search in October 2022 and August 2023 covered PubMed, Embase, Cochrane Library, SCOPUS, and Web of Science.

REVIEW METHODS

The search was limited to English-language studies published since 2008, considering this when propranolol was demonstrated as an effective treatment option for IH. The articles were screened for relevance based on predefined inclusion and exclusion criteria.

RESULTS

After inclusion and exclusion criteria, sixty final studies were identified, describing 240 cases of infantile SGH. Most children were diagnosed using OE alone (73.3%; n = 176/240), 23.3% (n = 56/240) using office-based laryngoscopy procedures (OBPs) followed by OE, 3.3% using OBP alone (n = 8/240). There were no reported diagnostic endoscopy-related complications. Twenty-nine studies described using endoscopy plus diagnostic imaging to either confirm an SGH lesion, characterize the extent of disease spread, or rule out other causes of presenting symptoms. The proportion of infants diagnosed with OE alone decreased from 2008 to 2023.

CONCLUSION

Operative endoscopy remains the SGH diagnostic standard, but OBP adoption is increasing. Further research is needed to determine the optimal SGH diagnosis and management approach.

LEVEL OF EVIDENCE

NA Laryngoscope, 2024.

Neonatal Stridor: Diagnosis and Management

Stridor, a common presenting sign of respiratory distress in a newborn, has many systemic causes. It may arise from the larynx or the tracheobronchial airway. This article presents the most common pathologic conditions in this anatomic region, with highlights on management.

The use of propranolol in the treatment of subglottic hemangiomas: A literature review and meta-analysis

OBJECTIVES

1) Describe the origins of the use of propranolol in the treatment of subglottic hemangiomas, 2) Perform meta-analysis of all case reports and series in which propranolol was used to treat subglottic hemangiomas.

STUDY DESIGN

Literature review and meta-analysis.

METHODS

A total of 61 cases were identified from 19 scholarly articles. Cases were assessed by parameters including age at diagnosis, presence of other hemangiomas, percent airway obstructed, dose of propranolol, treatment duration, age at therapy termination, use of steroids, and treatment failure. Treatment failure was defined as: 1) Need for surgery after initiation of propranolol, 2) Return of symptoms, or 3) Endoscopic worsening/recurrence of hemangioma. All data was subjected to comprehensive statistical analysis.

RESULTS

Though not statistically significant, a trend was noted towards a decreased treatment failure rate with increasing doses of propranolol (p = 0.0563). The use of concurrent steroids was associated with a higher failure rate (p = 0.0487). Notably, no associations were observed between the presence of additional hemangiomas, prior surgery, or increased initial percent airway obstruction with treatment failure.

CONCLUSION

Propranolol is rapidly becoming the standard of care in the treatment of subglottic hemangiomas. Despite widespread adoption, the rarity of this condition has limited previous studies to case reports and small series. No evidence-based guidelines exist for proper dosing of propranolol. The results of this meta-analysis suggest a benefit to higher doses of propranolol (3 mg/kg/day), though further investigation is needed.

Adverse Events in Young and Preterm Infants Receiving Topical Timolol for Infantile Hemangioma

BACKGROUND

The success of oral propranolol for treatment of infantile hemangiomas (IHs) has led practitioners to use topical β-blockers. In preterm infants, clinicians frequently turn to topical timolol, with the presumption that topical application will result in less systemic absorption. We used Holter monitoring to assess for drug-induced bradycardia in high-risk infants.

METHODS

We retrospectively reviewed the charts of 22 at-risk infants who received a Holter monitor to assess for association between timolol administration and development of significant bradycardia.

RESULTS

Four infants had episodic bradycardia detected by Holter monitoring. Two of these infants were full term; weighed more than 3,000 g; and had rare, brief, asymptomatic episodes unrelated to the timing of the timolol application. The other two infants had symptomatic bradycardia while on timolol and were the only two babies that weighed less than 2,500 g at initiation of therapy. Both were young (postmenstrual age [PMA] 34 and 37 wks) at initiation and had a timolol dose above the average exposure for the cohort.

CONCLUSION

In this cohort of at-risk infants, topical timolol appeared to provide safe treatment for IHs in full-term infants receiving a dose of less than 0.2 mg/kg/day, but infants with a PMA of less than 44 weeks and weight at treatment initiation of less than 2,500 g may be at risk of adverse events, including bradycardia, hypotension, apnea, and hypothermia. We recommend close monitoring of temperature, blood pressure, and heart rate in premature and low-birthweight infants with IHs at initiation of and during therapy with topical timolol.

Management of subglottic hemangiomas with carbon dioxide laser: Our 25-year experience and comparison with the literature

INTRODUCTION

Subglottic hemangiomas (SGH) are rare tumors of infancy arising between the perichondrium and the mucosa of the subglottic space. It is a potential life-threatening condition. Many therapeutic options exist for this disease, including lasers.

OBJECTIVE

To report our 25-year experience of laser treatment of SGH.

MATERIAL AND METHODS

Retrospective review of charts.

SETTING

Clarós' Otolaryngology and Head and Neck Surgery Clinic in Barcelona, Spain.

RESULTS

We recruited a total of 97 patients of whom 89 were treated with CO2 laser. Mean age at first contact was 2.1 months (range: 1.5-6.5). Sex ratio was 10 girls for 1 boy. Eighty percent of patients presented with stridor and 30.3% with recurrent acute laryngitis. Forty percent had associated cutaneous hemangiomas. They received an average of 1.85 laser session (range: 1-4) and 78.5% were healed after a maximum of 2. We had a 100% success rate and 1.1% complication rate (subglottic stenosis).

CONCLUSION

CO2 laser is a very effective and recommendable tool against subglottic hemangiomas. To achieve good results traditional laser safety measures should be respected besides some useful surgical tips.

Propranolol: Effectiveness and Failure in Infantile Cutaneous Hemangiomas

Infantile hemangiomas (IHs) occur in early infancy and are considered to be one of the most frequent childhood tumors. Poor responsiveness to the treatment and complications are reported in about 10 % of patients. For years, the most common treatments for cutaneous and complicated IHs were corticosteroids, interferon-α, vincristine, laser therapy, or surgical intervention. More recently, treatment with propranolol has been reported with high success rates, both in the cutaneous and complicated form of IHs, and it is now considered to be the first-line treatment for IHs. Herein we report five cases of cutaneous IHs who presented at our unit between January 2011 and June 2012: in three of five patients, the lesion improved soon after the beginning of propranolol treatment; one case presented slow but complete resolution; and in one patient the treatment was unsuccessful. Patients who do not respond to propranolol have been seldom reported in the literature. However, the failure of propranolol treatment in childhood hemangiomas has been more frequent in our experience than that reported in previous case series. More attention should be given to the cases that poorly or negatively respond to treatment, and to the mechanisms underlying the failure to respond to treatment with propranolol.

Office-Based Subglottic Evaluation in Children With Risk of Subglottic Hemangioma

PURPOSE

Children with V3 cutaneous infantile hemangiomas (IH) and PHACE syndrome have a high incidence for airway hemangioma, 29% and 52%, respectively. Therefore, a clinical evaluation for these high-risk children is essential. We report our experience with in-office lower airway evaluation (OLAE) in these high-risk children.

RESULTS

Since 2003, 5 children with IH of the V3 cutaneous distribution and 3 children with PHACE syndrome underwent OLAE. Average age of presentation was 2.75 months. Two children had stridor at initial evaluation, and 1 child had subglottic hemangioma. This child was evaluated serially with OLAE to monitor disease progression and treatment response. A total of 10 upper tracheoscopies were performed on the 8 patients without respiratory complications.

CONCLUSION

An airway evaluation is essential to evaluate and manage this high-risk population. Typically, operative endoscopy requires general anesthesia. However, in these high-risk children, we have performed OLAE without sedation to evaluate the trachea. High-speed recording and playback is essential in this method. Our series demonstrates that awake OLAE is possible and may be a safe technique to evaluate and monitor disease progression in these high-risk patients. These patients avoided general anesthesia and delay in diagnosis and did not incur any complications during or after OLAE.

The effectiveness of propranolol in treating infantile haemangiomas: a meta-analysis including 35 studies

AIMS

Propranolol may have shown excellent results as a first line therapy in infantile haemangiomas (IHs) at all sites in the body, but this conclusion remains controversial. In an attempt to resolve this issue, we performed a meta-analysis.

METHODS

A search of the literature using PubMed, MEDLINE, Cochrane Library databases and China National Knowledge Infrastructure (CNKI) was performed to identify studies which estimated the efficacy of propranolol therapy in infants with haemangiomas all sites of the body. The pooled odds ratio (OR) along with the corresponding 95% confidence intervals (CI) were assessed using a fixed effects model.

RESULTS

Thirty-five studies involving 324 infantile haemangioma(IH) patients and 248 controls were retrieved and analyzed. The efficacy of propranolol was greater than other therapies in treating IHs (OR = 9.67, 95% CI 6.62, 14.12, P < 0.001). In a stratified analysis by sites of tumour, propranolol was a more effective therapy when compared with steroids (OR = 9.67, 95% CI 6.61, 14.15, P < 0.001), vincristine (OR = 9.00, 95% CI 2.15, 37.66, P = 0.003) and laser treatment (OR = 9.00, 95% CI 1.42, 57.12, P = 0.020) in treating cutaneous IHs (OR = 24.95, 95% CI 9.48, 65.64, P < 0.001), peri-ocular IHs (OR = 9.39, 95% CI 3.88, 22.71, P < 0.001), infantile airway haemangiomas (OR = 20.91, 95% CI 7.81, 55.96, P < 0.001) and infantile hepatic haemangiomas (OR = 9.89, 95% CI 1.20, 81.54, P = 0.033).

CONCLUSION

The current meta-analysis provided strong evidence for propranolol as a first line therapy for IHs.

Intra-thyroidal hemangioma--a rare congenital anomaly: case presentation and literature review

Infantile hemangiomas (IH) present and evolve in a predictable way. In certain cases, however, they can be of clinical significance. IHs in the airway can cause significant respiratory distress. We present the first reported case of an intrathyroidal hemangioma to cause significant respiratory distress, which was successfully treated with propranolol and dexamethasone. A review of the literature was also performed.

Management of subglottic hemangioma with propranolol

Subglottic hemangioma is a rare but life- threatening condition which requires intervention. It generally starts proliferating in the first and second months of lifespan and whether there is a respiration problem or not, it causes biphasic stridor. Its diagnosis generally requires direct laryngoscopy or direct screening through bronchoscopy. This case report presents a 45-day-old girl who had subglottic hemangioma presenting with wheezing and stridor. Our case took propranolol with a dose of 2 mg/kg/day and within 48 h after the start of the treatment, obstructive symptoms started to alleviate considerably.

Propranolol treatment in life-threatening airway hemangiomas: a case series and review of literature

OBJECTIVES

Infantile hemangiomas (IHs) in the airway may be potentially life-threatening during the proliferative phase. Available treatments like oral corticosteroids (OCS) and chemotherapeutic agents usually showed variable responses and serious side effects. Propranolol is a new and promising treatment option.

METHODS

A case series of five IH patients with airway involvement is presented, supplemented with a review of literature. Propranolol treatment (2.0-3.0mg/kg/day) was initiated between 3 weeks and 6 months of age. Three cases were treated with propranolol monotherapy, 2 cases with OCS primarily and propranolol secondarily, in which treatment with OCS could be reduced rapidly.

RESULTS

In our case series a dramatic, fast response was observed in all cases, with a permanent effect after discontinuation in four cases. In one patient a relapse of airway problems occurred two months after discontinuation of propranolol at 16 months of age; this resolved after re-start of propranolol. Review of literature together with these five cases showed 81 patients with airway IHs treated with propranolol. Propranolol was effective in 90% of the cases and seven patients were classified as non-responders. Eight IHs relapsed while weaning of propranolol or after discontinuation; dose adjustment or restart was effective in most cases but one patient appeared resistant to therapy.

CONCLUSIONS

Propranolol seems to be a rapidly effective and safe treatment strategy for most IHs obstructing the airway. Because of the fast and important effects of propranolol, randomized controlled trials are hardly justifiable for this specific, relatively rare but, acute treatment indication. Despite the efficacy of propranolol, close monitoring of the patients with an airway IH is required, considering the risk of relapse of symptoms during or after treatment and the reported resistance to propranolol in at least 9% of the published cases. The dose and duration of treatment should be high and long enough to prevent relapse. Further research should focus on the optimal treatment protocol; the actual percentage of non-responders and also the mechanism of resistance to propranolol is unknown and needs to be illuminated.

Microdebrider removal under suspension laryngoscopy: an alternative surgical technique for subglottic hemangioma

OBJECTIVE

To describe microdebrider removal of subglottic hemangiomas and evaluate the efficacy of this procedure.

METHODS

This retrospective study was conducted at an otorhinolaryngology department. Seven consecutive patients with subglottic hemangiomas who failed to respond to pharmacologic treatment were treated by microdebrider removal under suspension laryngoscopy. Respiratory symptoms and hemangioma status were assessed preoperatively and postoperatively.

RESULTS

The mean age of patients at disease onset was 68 days (range, 24-120 days), and their mean age at the time of surgical treatment was 132 days (range, 55-195 days). Their initial pharmacologic treatment included steroids, propranolol, and/or antibiotics. The mean percentage of airway obstruction was initially 36% (range, 30-50%), and this value changed to 61% (50-80) before surgery. Microdebrider removal of hemangiomas was successful in all patients without any intraoperative or postoperative complication. The mean operative time was 30 min (range, 21-47 min). Three patients required orotracheal intubation for 12 or 24h after surgery, and no reintubation or tracheotomy was required in this series. Symptoms such as stridor and inspiratory retraction were resolved approximately 72 h after surgery, but wheezing was generally resolved at a later time point. One year later, no respiratory symptom was noted in these patients, and endoscopic examination revealed a sufficient glottis opening.

CONCLUSIONS

Surgical removal with a microdebrider is advantageous as a routine surgical technique for small and moderate pediatric subglottic hemangioma.

Update on infantile hemangiomas

Infantile hemangiomas are the most common tumors of infancy. The serendipitous discovery of the therapeutic efficacy of propranolol in the management of infantile hemangiomas has revolutionized the care and understanding of these lesions, and greatly improved the prognosis for a good cosmetic outcome. In addition, there has been an expansion of indications for treatment of hemangiomas, taking into account not only those hemangiomas that can cause airway compromise, amblyopia, and cardiac overload, but also those lesions that can lead to unsatisfactory cosmetic outcome or deformity after involution. Current concepts of pathogenesis of infantile hemangiomas, of segmental hemangiomas with systemic associations, of hepatic hemangiomas, and of the use of systemic and topical beta-blockers for the management of IH are all reviewed.

Initiation and use of propranolol for infantile hemangioma: report of a consensus conference

Infantile hemangiomas (IHs) are common neoplasms composed of proliferating endothelial-like cells. Despite the relative frequency of IH and the potential severity of complications, there are currently no uniform guidelines for treatment. Although propranolol has rapidly been adopted, there is significant uncertainty and divergence of opinion regarding safety monitoring, dose escalation, and its use in PHACE syndrome (PHACE = posterior fossa, hemangioma, arterial lesions, cardiac abnormalities, eye abnormalities; a cutaneous neurovascular syndrome characterized by large, segmental hemangiomas of the head and neck along with congenital anomalies of the brain, heart, eyes and/or chest wall). A consensus conference was held on December 9, 2011. The multidisciplinary team reviewed existing data on the pharmacologic properties of propranolol and all published reports pertaining to the use of propranolol in pediatric patients. Workgroups were assigned specific topics to propose protocols on the following subjects: contraindications, special populations, pretreatment evaluation, dose escalation, and monitoring. Consensus protocols were recorded during the meeting and refined after the meeting. When appropriate, protocol clarifications and revision were made and agreed upon by the group via teleconference. Because of the absence of high-quality clinical research data, evidence-based recommendations are not possible at present. However, the team agreed on a number of recommendations that arose from a review of existing evidence, including when to treat complicated IH; contraindications and pretreatment evaluation protocols; propranolol use in PHACE syndrome; formulation, target dose, and frequency of propranolol; initiation of propranolol in infants; cardiovascular monitoring; ongoing monitoring; and prevention of hypoglycemia. Where there was considerable controversy, the more conservative approach was selected. We acknowledge that the recommendations are conservative in nature and anticipate that they will be revised as more data are made available.