Treatment of oral hemangiomas with local sclerosing agents

Usefulness of a Low-Dose Sclerosing Agent for the Treatment of Vascular Lesions in the Tongue

Hemangiomas and vascular malformations are common benign lesions of vessels in the cervical region. However, the lesions may not completely disappear and may require surgical or nonsurgical intervention. Several treatment options, including surgical excision, steroid injection, laser therapy, and sclerotherapy, are available. Surgical excision is a commonly used treatment; however, in cases of hemangiomas of the tongue, excision of the lesion may cause esthetic or functional impairments, including speech and swallowing. Sclerotherapy is a simple and safe method for treating vascular lesions conservatively. In this case report, two patients with a vascular lesion of the tongue underwent conservative sclerotherapy without surgical excision using a sclerosing agent (sodium tetradecyl sulfate). Both patients showed regression of the lesion without complications. As presented in these cases, repeated injections of low-dose 1% sodium tetradecyl sulfate as a sclerosing agent were safe and showed satisfactory outcomes.

Transposition Mucosal Flap Combined With Autologous Fat Transplantation to Repair Lip Defects Caused by Sclerotherapy of Hemangioma

ABSTRACT

Infantile hemangiomas are the most common benign childhood tumors and can occur on any part of the human body. Sclerosing agents are used in the early stage of treatment of infantile hemangioma. Sometimes a lip defect remains after sclerosing agent treatment. We developed a simple technique to repair lip defects. The authors performed transposition mucosal flap and autologous fat transplantation surgery on patients who had lip defects caused by sclerosing agents. The flap was transposed 90° from the intraoral labial mucosa to the vermilion defect. Autologous fat was transplanted to the white lip defect. If necessary, a secondary fat transplantation may be performed every half year. All patients were followed up to evaluate the effect of the operation. Patients were asked to rate their satisfaction with the surgery between 1 and 10. Digital three-dimensional evaluation was performed. Sixteen patients underwent the surgery successfully, and the flaps were all viable. No complications occurred after surgery (5 males, 11 females; age range, 5-27 years; 12 upper lip, 3 lower lip, and 1 median lip). The patients were satisfied with the aesthetic outcome of surgery (mean score, 9). Seven patients wanted to undergo a second fat transplantation, whereas 9 patients felt it was unnecessary to transplant fat again. Transposition mucosal flap combined with autologous fat transplantation is reliable and minimally invasive. It is an effective method for repairing moderate lip defects mainly involving vermilion caused by a sclerosing agent.

Vascular anomalies of the head and neck: diagnosis and treatment

Vascular malformations and vascular tumors comprise the two specific subsets of vascular anomalies that arise as a result of disorganized angiogenesis and neoplasm, respectively. Malformations are separate entities from vascular tumors (e.g., hemangiomas) and are recognized by the International Society for the Study of Vascular Anomalies (ISSVA) as such. Vascular malformations are classified into four main groups: simple, combined, anomalies of major vessels, and those associated with other vascular anomalies. Vascular tumors are neoplastic growths of blood vessels and are morphologically and molecularly distinct from malformations but can arise in the head and neck and have syndromic association. Head and neck vascular anomalies are not uncommon in the pediatric population and require special care in the workup, diagnostic imaging and clinical care. The purpose of this manuscript is to discuss the diagnosis and management of the most common intracranial and extracranial vascular malformations and tumors in the head and neck in children and adolescents.

What is the preferred concentration of ethanolamine oleate for sclerotherapy of oral vascular anomalies?

Background

This study compared three different concentrations of EO (1.25%, 2.5% and 5%) for the treatment of oral vascular anomalies (OVAs).

Material and Methods

This was a retrospective comparative analysis of patients with OVAs treated with EO. Anomalies smaller than 20 mm were included. The patients were treated with 1.25% (G1), 2.5% (G2), and 5% (G3) and clinical data were obtained. The number of sessions, the final volume and dose of EO were statistically analyzed to verify effectiveness and safety of the treatment. The different concentrations of EO were compared considering the number of sessions, the final volume and total dose of EO. Analysis of covariance (ANCOVA) was used to evaluate the influence of covariates on the outcomes. A p-value < 0.05 was considered significant.

Results

Nineteen women and 11 men with a median age of 54 years were included. The OVAs were most frequent in the lip (n=14) and cheek (n=9). All lesions exhibited complete clinical healing within 28 days. Patients of G3 required fewer sessions than those of G2 (p=0.017), a lower final volume compared to the other groups (p<0.001), and a lower total dose than G1 (p<0.001). Patients of G1 used a lower total dose than G2 (p=0.003).

Conclusions

The concentration of 5% EO performed better than 1.25% and 2.5% for sclerotherapy of OVAs measuring up to 20 mm. This preliminary result should be the preferred concentration of EO to provide an effective and safe treatment of OVAs.

Key words:Ethanolamine oleate, sclerotherapy, vascular malformations, hemangioma, oral mucosa.

Effects of sclerosing agents on head and neck hemangiomas: A systematic review

Background

The aim of this study was to systematically review the literature for studies that investigated the effects of sclerosing agents on head and neck hemangiomas.

Material and Methods

Clinical trials, cohort studies, and descriptive studies were considered eligible and selected in a two-phase process. Six main electronic databases, in addition to three grey literature databases, were searched. Risk of bias (RoB) was assessed using the “Meta-Analysis of Statistics Assessment and Review Instrument” checklist. From fifty-six considered eligible, five were finally included.

Results

One article were judged at low, one at moderate, and three at high RoB. The sclerosing agents investigated were sodium tetradecyl sulphate (n=2), ethanolamine oleate (n=1), pingyangmycin (n=1) and bleomycin (n=1). Overall, good results were achieved on the treatment of head and neck hemangiomas with intralesional sclerotherapy. Most commonly reported adverse effects included pain, swelling, fever, necrosis, transient facial palsy, and anorexia.

Conclusions

Considering the limited number of included studies, intralesional sclerotherapy on the management of HN hemangiomas presented overall good results with minor adverse reactions, especially in regards to smaller lesions.

Key words:Sclerotherapy, sclerosing solutions, vascular neoplasms, hemangioma.

Sodium Tetradecyl Sulfate: A Review of Clinical Uses

BACKGROUND

Sodium tetradecyl sulfate (STS) is Food and Drug Administration approved for treatment of varicose veins, but numerous other off-label applications have been reported.

OBJECTIVE

To describe the clinical uses of STS, as well as efficacy and adverse effects.

METHODS

Review of studies searchable on PubMed from 1938 to 2016 describing clinical uses of STS to determine efficacy and adverse effects associated with various applications.

RESULTS

Sodium tetradecyl sulfate has shown efficacy in the treatment of varicose veins, telangiectasias, hemangioma, pyogenic granuloma, cherry angioma, Kaposi sarcoma, lymphangioma circumscriptum, digital mucous cyst, ganglion cyst, glomangioma, angiokeratoma of Fordyce, pseudocyst of the auricle, and verruca. Commonly reported side effects include pain, erythema, swelling, hyperpigmentation, telangiectatic matting, and ulceration. Serious side effects such as anaphylaxis, pulmonary embolism, stroke, and myocardial infarction have also been reported. Most sources were case reports and small prospective studies, as such the strength of data supporting many uses is limited by small sample sizes and lack of controls.

CONCLUSION

Although not always the most effective method of treatment in off-label usage, use of STS has been frequently selected for a variety of applications for reasons of simplicity, low cost, lack of availability of technologically advanced equipment, and intricacies related to anatomic location.

Sclerotherapy of Intraoral Superficial Hemangioma

Hemangioma is the clinical term for a benign vascular neoplasm due to proliferation of the endothelial lining of blood vessels. Their most frequent location is the body skin and oral mucosa. One of the treatment modalities for hemangiomas is intralesional injection of sclerosing agents which cause the damage of blood vessels followed by their obliteration. The objective of the study was to describe the facility of application and evaluate the efficiency of sclerotherapy with aethoxysklerol 1%. Method. The case presented with intraoral submucosal hemangioma of the cheek was treated by intralesional injection of aethoxysklerol 3% diluted in water for injections at a 4 : 1 ratio (0.75%) at the first appointment and 3 : 1 (1%) at the second appointment. The effect of sclerotherapy was evaluated on the following visits in time intervals of two weeks. Results. The hemangioma disappeared without complications after the second injection of aethoxysklerol 1%. The successful results of the study were comparable to the data of literature with variations according to the used sclerosant agent, its concentration, the number of injections, and the intervals between each session. Conclusion. Since sclerotherapy is a very effective, inexpensive, and easy-to-apply treatment, it should be the treatment of choice, especially for intraoral superficial hemangiomas.

Injection Snoreplasty: Investigation of Alternative Sclerotherapy Agents

OBJECTIVE: Palatal sclerotherapy with sodium tetradecyl sulfate (“injection snoreplasty”) was recently introduced as a safe and effective treatment for primary snoring. However, multiple other sclero-therapy agents also have excellent safety records and documented efficacy in the head and neck. Widely available and inexpensive agents were evaluated as potential palatal sclerosing agents for the treatment of snoring.

STUDY DESIGN AND SETTING: A described canine palatal flutter model was used to evaluate the palatal stiffening efficacy of ethanol, doxycycline, and hypertonic saline in comparison to 3% sodium tetradecyl sulfate (STS) and a negative control (normal saline). Based on the animal study results, a human pilot study with ethanol was performed with subjective and objective data.

RESULTS: Ethanol was found to be equally effective as 3% STS in the canine model. Doxycycline was effective but less so, and hypertonic saline was comparatively ineffective. Palatal injection in human patients with 50% ethanol was found to produce equivalent subjective and objective snoring efficacy and equivalent pain and recovery time compared with 3% STS. However, there was a higher rate of transient palatal fistula with ethanol. CONCLUSIONS AND SIGNIFICANCE: Injection snoreplasty with 50% ethanol is equally efficacious compared with 3% STS. There could be a higher fistula rate with the use of ethanol, although this complication has been self-limited and transient in every case.

A new venture with sclerotherapy in an oral vascular lesion

Vascular malformations are one of the most common lesions of the oral cavity. The lesion may be a congenital malformation observed in neonates or arteriovenous malformation observed in adults. Various surgical and medical managements are possible for vascular lesions which include surgical excision, laser therapy, cryotherapy, selective embolization, intralesional sclerosing agents, β-blockers and steroid therapy. Here we report a case of oral vascular lesion where intralesional injection with 30 mg/ml of sodium tetradecyl sulfate (STS) was given, which resulted in local complications with severe inflammatory response including pain, swelling, and surface ulceration that remained for 2 weeks. Sclerotherapy with STS still remain an effective agent in treating benign oral vascular lesions and provides alternative or support for surgical methods. Sometimes it can lead to undesirable complications like allergic reactions, local inflammatory response, etc.

Management of haemangioma with sclerosing agent: a case report

The use of multiple weekly intralesional injections of 3% sodium tetradecyl sulfate as a sclerosing agent for the management of facial haemangiomas is a safe treatment with acceptable results. As presented in this case report, this technique offers the patient considerable relief of symptoms with minimal complications. However, the possibility of second-stage surgery to correct residual deformity is still considered. Sclerotherapy with 3% sodium tetradecyl sulfate provides a good preparation for further surgery.

Hemangioma: review of literature

Hemangiomas are tumors identifed by rapid endothelial cell proliferation in early infancy, followed by involution over time. All other abnormalities are malformations resulting from anomalous development of vascular plexuses. The malformations have a normal endothelial cell growth cycle that affects the veins, the capillaries or the lymphatics and they do not involute. Hemangiomas are the most common tumors of infancy and are characterized by a proliferating and involuting phase. They are seen more commonly in whites than in blacks, more in females than in males in a ratio of 3:1.

Sodium tetradecyl sulphate sclerotherapy for treating venous malformations of the oral and pharyngeal regions in children

OBJECTIVE

Venous vascular malformations in the head and neck region present a difficult management challenge. We describe our experience of using sodium tetradecyl sulphate injection sclerotherapy to treat children presenting with venous malformations of the oral and pharyngeal region.

METHODS

We performed a retrospective case note review of consecutive children treated at our institution between 2004 and 2011. Patient notes were analysed for demographic details, site and size of lesion, number and duration of treatments, treatment response and complications.

RESULTS

Twelve patients were included (7 boys and 5 girls, mean age 7 years). Sites of lesions included tongue, floor of mouth, pharynx, tonsillar fossae, parapharyngeal space and soft palate. All patients were treated with 3% sodium tetradecyl sulphate (STS) foam injected trans-orally or percutaneously under ultrasound or fluoroscopic guidance. The lesions had a mean volume of 4 ml (range 2-14 ml). An average of 3 treatments was required (range 1-9). In 4 patients a single treatment was sufficient. For those patients requiring multiple treatments, a mean of 4 treatments were required over an average period of 28 months. The overall response rate was 83% (10/12). Complete resolution was achieved in 4 cases (33%) with a significant reduction in size in a further 6 cases (50%). Larger lesions generally require more treatments than low volume lesions. Two cases recurred despite treatment. One patient suffered minor bleeding following transcutaneous injection.

CONCLUSIONS

Injection sclerotherapy using STS foam offers an effective treatment option when managing children presenting with venous malformations in the oral and pharyngeal. A single treatment may be adequate for small lesions but the procedure may be safely repeated until a satisfactory result is obtained.

Comparative analysis of intralesional sclerotherapy with sodium tetradecyl sulfate versus bleomycin in the management of low flow craniofacial soft tissue vascular lesions

OBJECTIVE

Comparison of the efficacy of bleomycin over sodium tetradecyl sulfate (STS) when given intralesionally in the treatment of oral and maxillofacial venous malformation.

METHODS

16 patients with venous malformation in craniofacial region were randomly divided into two groups of eight. Group 1 was given intralesional injection of bleomycin and group 2 was injected with STS. All the cases were evaluated for a minimum period of two and a maximum of 3 years.

RESULTS

Efficacy of bleomycin was found to be superior to STS, when used as intralesional sclerotherapic agent. Most of the vascular lesions of group 1 resolved after first dose giving a cure rate of 87.5% and no recurrence was observed. Group 2 patients however, required 4-6, a mean of five repeated dosage of intralesional STS before their lesions started to resolve and three patients reported with recurrence within 2 years, giving an overall effective response rate of 62.5%.

CONCLUSION

Bleomycin under selected conditions appears to be an excellent therapy for treating soft tissue vascular lesions of low flow nature in craniofacial region. Predictable results were obtained with a high success rate. No systemic or pulmonary complications occurred.

Treatment of oral hemangioma with 3% sodium tetradecyl sulfate: study of 20 cases

Hemangiomas possess an extremely challenging treatment dilemma for surgeons and the patients. Most of the hemangiomas involute but if they don't involutes or impair the vital functions or occur in adults they need intervention. Present study was conducted to evaluate and discuss the response of sclerosing agent 3% sodium tetradecyl sulfate (STDS) in oral hemangioma. All 20 cases of hemangioma were diagnosed clinically and were treated with 3% sodium tetradecyl sulfate (STDS) injections locally at regular intervals depending upon the size of the lesion. Hemangioma regressed in all the cases with considerable relief of symptoms with minimal complications. When used in appropriate doses, Sclerosing agent, 3% sodium tetradecyl sulfate (STD), is very effective for treatment of oral hemangioma.

Chronic facial pain following injection of sodium tetradecyl sulphate into an intraparotid haemolymphangioma

Objective:

We report a rare case of chronic facial pain following sclerotherapy for intraparotid haemolymphangioma, thereby highlighting an important clinical consideration when advising this treatment option as an alternative to surgery in the head and neck.

Method:

Case report, with a review of relevant literature.

Results:

Sclerotherapy of lymphangiomata is well reported in the literature. Unusually, our young patient with an intraparotid haemolymphangioma experienced severe, chronic pain following intralesional injection of sodium tetradecyl sulphate, which required management by a specialist pain service. We discuss the technique of sclerotherapy for such lesions, and also discuss the potential side effects of two agents commonly used in our centre: OK 432 and sodium tetradecyl sulphate.

Conclusion:

Non-surgical treatments of lymphangiomata and venous vascular malformations are not without complication. Both patient and clinician should be aware of this, and of the other potential side effects of sclerotherapy, prior to its use in the head and neck.

Sclerotherapy of benign oral vascular lesion with ethanolamine oleate: An open clinical trial with 30 lesions

OBJECTIVE

The objective of this study was to report and discuss the results from treatment of benign oral vascular lesions with ethanolamine oleate.

STUDY DESIGN

Twenty-seven patients with 30 examples of oral vascular malformation, hemangioma, or varix were treated with intralesional injections of 1.25% or 2.5% ethanolamine oleate at an interval of 15 days between each application. The lesions were divided into 2 categories: (1) lesions of 20 mm or less and (2) those greater than 20 mm. Subsequently, the Mann-Whitney test was used a means of statistical analysis.

RESULTS

Although the number of injections varied from patient to patient, all lesions responded to the treatment, showing total clinical regression. Lesions of 20 mm or less needed a lesser number of applications than those greater than 20 mm (P < .05).

CONCLUSIONS

Ethanolamine oleate is a 100% effective sclerosant agent for treatment of benign oral vascular lesions. In this study, no difference was found between the 2 concentrations applied.

Injection snoreplasty: how to treat snoring without all the pain and expense

OBJECTIVE

We introduce Injection Snoreplasty: an innovative, safe, and effective palatal snoring procedure with minimal cost and discomfort to the patient. A well-described sclerotherapy agent, Sotradecol, is injected into the soft palate to reduce/eliminate palatal flutter snoring.

STUDY DESIGN AND SETTING

Twenty-seven patients with a diagnosis of palatal flutter snoring (respiratory disturbance index less than 10) by sleep study were enrolled in the protocol. Office treatment sessions were performed 6 to 8 weeks apart. Success was judged by subjective improvement in snoring and objective evidence of palatal stiffening/scarring.

RESULTS

Twenty-five (92%) of 27 patients reported significant decrease in snoring. There were no significant postinjection complications. Visual analog pain scale confirmed minimal discomfort. Most patients received more than 1 treatment (average, 1.8) in order to receive optimal palatal stiffening.

CONCLUSION/SIGNIFICANCE

Injection Snoreplasty is a simple, safe, and effective office treatment for primary snoring. Advantages over current snoring procedures include simplicity, low cost, decreased posttreatment pain levels, and minimal/no convalescence.

Color duplex-guided sclerotherapy for the treatment of venous malformations

BACKGROUND

Although surgical extirpation is the standard method for the treatment of vascular malformations, this procedure often leads to loss of motor function, nerve damage, and massive bleeding if the excision is extensive. Sclerotherapy is an alternative method of treatment for venous malformations.

OBJECTIVE

This study was conducted to assess the effect of color duplex ultrasound-guided sclerotherapy on venous malformations and the coagulability induced by sclerosing solution.

METHODS

Twenty-eight patients with venous malformations underwent percutaneous sclerotherapy by direct puncture under duplex ultrasound guidance. Intravenous catheters were inserted into duplex ultrasound-confirmed venous spaces and fine plastic tubing filled with normal saline was attached to the needle. When the needle tip was observed to pierce the vein wall, aspiration of the blood confirmed its intraluminal position. The mean volume of 3.6 ml of 3% polidocanol was injected. Subfascial ligation of the lateral marginal venous collector was performed in patients with Klippel-Trenaunay syndrome. D-dimer (DD) and thrombin-antithrombin III (TAT) were measured preoperatively and on the first and fifth postoperative days.

RESULTS

The head and neck, which was the most common site of venous malformations were involved in 57% of the patients. Venous malformations disappeared in 44% of the patients and decreased in 28%. Localized pain was the most common complication, occuring in 82% of the patients. Sclerotherapy for venous malformations produced significant swelling in 75% of the patients, which required 5-7 days to subside. Significant differences were detected in both DD and TAT concentrations on the first and fifth postoperative days.

CONCLUSIONS

Color duplex-guided sclerotherapy was effective in 82% of the patients. This procedure prevents intra-arterial injection accidents. Although patients with venous malformations showed greater coagulability, no serious thrombotic sequelae were found.

Central arteriovenous malformations of the maxillofacial skeleton: case report

Central arteriovenous malformation of the maxillofacial skeleton, though rare, is a well-documented entity. Past treatments have usually included some form of surgical intervention. Surgical resection as an attempt to cure has been effective but costly, ie, in relationship to patient morbidity and hospital expenditures. A case of vascular malformation is presented in which selective angiography and embolization as a primary treatment were used rather than ablative surgery. The patient tolerated the procedures well, with complete resolution of bleeding.

Treatment of angiomas with sclerosing injection of hydroxypolyethoxydodecan

The authors discuss the indications for hydroxypolyethoxydodecan in the sclerosing treatment of angiomas, with particular reference to cavernous, venous, and evolutive angiomas (ie, immature angiomas that fail to involute by eight to ten months). Moreover, the sclerosing agent may be employed, in connection with embolization and subsequent surgery, in arteriovenous angiomas with a relevant cutaneous-subcutaneous development. The authors have successfully used the "interstitial" sclerosing technique, according to Andrews' method. This technique involves interstitial injections to obtain the sclerosis of the thin threads of fibrous tissue stroma between the blood vessels. The sclerosing therapy may cause the complete regression of "low flow" angiomas or, at least, a partial reduction that simplifies the ensuing surgical excision. In the case of partial regression of the angioma obtained with the sclerosing therapy, the surgery of the remaining angioma causes a lesser degree of bleeding (especially in areas that do not particularly lend themselves to surgical exploration, ie, the oral cavity); an increased reliability in the radicality of the intervention (due also to the reduced size of the lesion); and better results from an aesthetic-functional point of view.

Oral hemangioma treated with a sclerosing agent. Report of a case

A case of oral soft tissue hemangioma is reported. The treatment of the lesion with a sclerosing agent is described.

The treatment of facial haemangioma by percutaneous injections of sodium tetradecyl sulfate

Sotradecol--sodium tetradecyl sulfate--is a sclerosing agent which has been used for years in the treatment of varicose veins, haemorrhoids and haemangiomata. Two cases of large haemangioma of the cheek are presented. Because surgical treatment posed many difficulties we decided to treat with sodium tetradecyl sulfate. Treatment was successful.

Vascular anomalies of the maxillofacial region

A biologic classification based on clinical behavior and endothelial cell characteristics is used to divide vascular birthmarks into two groups: hemangiomas and vascular malformations. This system is applied to vascular anomalies of the maxillofacial region and is demonstrated with illustrative cases. The distinction between hemangioma and vascular malformation is important for maxillofacial surgeons because hemangiomas rarely affect bone, whereas malformations affect bone in 35% of cases.

Treatment of maxillary hemangioma with a sclerosing agent

This article reports the case of a patient with a reasonably large maxillary hemangioma involving bone and overlying mucosa. A dramatic shrinkage of the lesion over a 4-week period was noted when sodium morrhuate was used as the sclerosing agent. Four and one half years following therapy, no recurrence of the tumor was noted. Radiographically, the area of involvement had become significantly more dense, with an increase in size and calcification of phleboliths in the area.