Significant hemangiomas and vascular malformations of the head and neck: clinical management and treatment outcomes

A nationwide cohort study on incidence and mortality associated with extracranial vascular malformations

Extracranial vascular malformations are abnormal formations of blood vessels located outside the brain (extracranial) that develop during fetal development. They are caused by errors in the formation of blood vessels in the embryo and can affect various parts of the body, such as the head, neck, face, and other regions. Some malformations may be asymptomatic and only require monitoring, while others may cause significant health issues or cosmetic concerns and may need medical intervention. There are very few studies have investigated the nationwide incidence and quantitative mortality of vascular malformations in terms of their subtypes. Thus, this study aimed to determine the nationwide incidence and mortality associated with vascular malformations. This nationwide population-based study evaluated 70,517 patients with vascular malformations from 2008 to 2021. We evaluated the incidence and mortality associated with each subtype of vascular malformation. Furthermore, Cox regression analysis was used to evaluate the association between vascular malformation and mortality. The annual incidence (per 100,000 population) of overall vascular, venous, capillary, arteriovenous, and lymphatic malformations was 9.85, 1.48, 2.31, 0.24, and 5.82 cases, respectively. Patients with vascular malformations, except those with venous malformations, had higher mortality than the matched controls. Moreover, among the vascular malformation subgroups, the adjusted hazard ratio of mortality was the highest for arteriovenous malformations. This study revealed that the overall annual incidence of vascular malformations was 9.85 cases per 100,000 population in Korea from 2008 to 2021. The mortality of the matched general population was lower than that of patients with vascular malformations, except for those with venous malformations. Additionally, the adjusted hazard ratio for mortality associated with arteriovenous malformations was the highest among the vascular malformation subgroups.

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.

Foam Polidocanol Sclerotherapy for Low-Flow Vascular Malformations of Tongue

INTRODUCTION

Low-flow vascular malformations (LFVMs) of the tongue are one of the most common presentations among different vascular anomalies of oral and maxillofacial regions. The present study was conducted with the objective to assess the outcome of a simple, easily available, safe and cost-effective therapeutic measure using foamed polidocanol in patients with LFVMs of the tongue.

MATERIALS AND METHODS

Fifteen patients with LFVMs of tongue were randomly selected in the study from the pool of 32 individuals affected with vascular malformation of oral and maxillofacial region. The diagnosis was made by a combination of clinical presentation and Doppler ultrasound. Lesions on the tongue were measured along their longer axis using a calliper and assigned to one of the three groups according to size: small-sized (<1 cm; 3 patients), medium-sized (between 1 and 3 cm; Four patients), or large-sized (>3 cm; eight patients). Foam sclerotherapy was done by directly injecting the foam (polidocanol) into identified sinusoids, under real-time ultrasound guidance. Foam polidocanol was prepared using the Tessari method.

RESULTS

Fifteen patients (Nine males and Six females), aged 7-50 years, with an average age of 23.53 years were included in our study. Of these 15 vascular lesions, three were small (<1 cm), four were medium (1-3 cm) and eight were large (>3 cm) in size. Treatment results were evaluated based on a reduction in lesion size. Complete or partial regression of lesions was reported by 14 (93.33%) patients and remained unchanged in one (6.67%) patient. The number of sclerotherapy sessions performed in this study ranged from 1 to 6 and was directly related to lesion size. Small- and medium-sized lesions responded well and complete resolution was seen in 1-3 sessions. Of the eight large lesions, seven showed complete or partial resolution in 4-6 sessions except one lesion which did not show any responses in subsequent sessions.

CONCLUSION

Foam polidocanol therapy for LFVM of tongue is cost-effective, less invasive and with added advantage of local anesthetic effect.

Balloon and Coil Occlusion of a Superior Sagittal Sinus Cortical Vein Facilitates Percutaneous Supraorbital Venous Malformation Sclerotherapy

Venous malformations are the most common of all vascular anomalies. Venous malformations are treated using a multidisciplinary approach with sclerotherapy representing the primary treatment modality. While rare, sclerotherapy in the central nervous system carries the risk of venous thrombosis, non-target embolization, and venous infarction and hemorrhage. Options for controlling venous outflow when treating venous malformations in the head and neck are limited. This report details the use of balloon and coil occlusion of a superior sagittal sinus cortical vein to facilitate percutaneous sclerotherapy of a supraorbital venous malformation.

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.

Immunohistochemical and histochemical characterization of intraosseous arteriovenous malformations of the jaws: analysis of 16 cases with emphasis on GLUT-1 immunophenotype

OBJECTIVES

Intraosseous vascular lesions of the craniofacial region are rare and may cause diagnostic and therapeutic challenges. The purpose of this study was to characterize 16 cases of intraosseous arteriovenous malformations (AVMs) affecting the jaws.

STUDY DESIGN

Immunohistochemical evaluation was performed using antibodies against α-smooth muscle actin (α-SMA), desmin, CD31, D2-40, and glucose transporter 1 (GLUT-1). Staining with elastic Verhoeff-Van Gieson and Masson trichrome histochemical stains was also performed.

RESULTS

No gender predilection (female:male ratio = 1:1) was observed, with patients' mean age being 50.8 years (SD of ±13.9; range 28-71 years). Predilection for the mandible was observed (12 of 16 [75%]). Immunohistochemically, diffuse endothelial CD31 staining was noted, and α-SMA strongly highlighted smooth muscle cells and pericytes. Desmin-positive vessels were identified in 9 of 16 AVMs (56.3%). D2-40 was uniformly negative in all specimens. AVMs were negative for GLUT-1 (11 of 14 [78.6%]) except for 2 cases (2 of 14 [14.3%]) exhibiting focal limited cytoplasmic GLUT-1 immunoreactivity. One case was equivocal for GLUT-1. Masson trichrome highlighted smooth muscle cells, and elastic fibers were identified in thick-walled arteries.

CONCLUSIONS

AVMs of the jaws generally lack expression of GLUT-1, similar to soft tissue vascular malformations. Clinicoradiographic features of intraosseous AVMs in the present study were consistent with the findings of previous studies, although mean age was higher.

IATROGENIC OCCLUSION OF THE OPHTHALMIC ARTERY AFTER SODIUM TETRADECYL SULFATE INJECTION IN THE FOREHEAD

PURPOSE

To describe a patient with ophthalmic artery occlusion after sodium tetradecyl sulfate foam injection in the forehead.

METHODS

In this case report, a description of the clinical examination and imaging findings, including fundus photography, spectral-domain optical coherence tomography, and fluorescein angiography are reported.

RESULTS

A 33-year-old white woman presented with severe painless vision loss in the left eye after cosmetic treatment of a forehead vein with sodium tetradecyl sulfate foam. Her visual acuity in the left eye was hand motions, and her fundus revealed diffuse retinal whitening in the macula with the absence of a cherry red spot and disruption of the arteriolar blood supply. Spectral-domain optical coherence tomography revealed intense hyperreflectivity of the inner and outer retina with loss of the foveal contour, and fluorescein angiography revealed delayed filling of the choroidal vasculature and cilioretinal artery with incomplete filling of the retinal arterioles in the late frames consistent with ophthalmic artery occlusion.

CONCLUSION

This case represents a devastating ocular complication after the inadvertent injection of sodium tetradecyl sulfate into a forehead artery, resulting in occlusion of the ophthalmic artery and severe vision loss.

Evaluation of embouchure dysfunction: Experience of 139 patients at a single center

OBJECTIVES/HYPOTHESIS

Our aims are to 1) illustrate the complexity and phenomenological richness of the embouchure; 2) delineate the main clinical features of non-dystonic embouchure problems (NED) versus embouchure dystonia (ED); and 3) provide a practical framework for physicians who may encounter a patient with embouchure dysfunction.

STUDY DESIGN

We performed retrospective chart and video review and report 139 instrumentalists with embouchure dysfunction evaluated over a 15-year period.

RESULTS

Included in this group are 109 ED patients (20 newly reported and 89 previously published) and 30 NED patients. Non-dystonic embouchure problems included the overuse syndrome, infraorbital neuropathy, and orbicularis oris tears, among others.

CONCLUSIONS

Based on this experience, the largest series presented to date, we propose a practical guide to help evaluate patients with embouchure dysfunction in the office.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1327-1333, 2016.

Efficacy of doxycycline and sodium tetradecyl sulfate sclerotherapy in pediatric head and neck lymphatic malformations

OBJECTIVES

Lymphatic malformations are congenital vascular anomalies that occur from abnormal development of the lymphatic channels. Studies have shown that sclerotherapy can be a reliable alternative to surgery. The purpose of this retrospective study is to evaluate the safety and efficacy of percutaneous sclerotherapy with doxycycline and 3% Sotradecol as primary treatment for pediatric head and neck LMs, and to assess outcomes based on lesion classification, location and sclerosant used.

STUDY DESIGN

This study was a single center, retrospective, case series study.

MATERIALS AND METHODS

The medical records of 38 children who underwent percutaneous sclerotherapy of LMs in the head and neck region at our tertiary care center between 1/1/2006 and 1/31/2011 were reviewed. A mean average of 2.9 (range 1-10) sclerotherapy sessions per child were performed. LMs involved primarily the face (61.3%), posterior neck (48.4%), submental area (45.2%), and anterior neck (35.5%).

RESULTS

Twenty-nine subjects had adequate follow-up data, with 51.7% demonstrating complete resolution, 27.6% moderate improvement, and 20.7% no response. There was no significant difference in the outcome based on the sclerosant agent used or location of the lesion. Lesion type did affect outcome and macrocystic lesions were found to have a significantly higher resolution rate (95.2%) than microcystic or mixed lesions (p < 0.05). The total number of complications was similar between agents and all were minor.

CONCLUSION

Our results indicate that percutaneous therapy with doxycycline and Sotradecol is safe and effective for children with LMs of the head and neck. Better outcomes were observed with macrocystic LMs.

LEVEL OF EVIDENCE

4.

Ethanol sclerotherapy of head and neck venous malformations

OBJECTIVE

This retrospective study evaluated the results of sclerotherapy with low doses of ethanol for treatment of head and neck venous malformations.

METHODS

We treated 51 patients, 37 females. Median age was 23 years. Patients were treated with percutaneous intralesional injection of alcohol every two weeks and followed up prospectively for a median period of 18 months. Most lesions affected the face and cosmetic disfigurement was the most frequent complaint.

RESULTS

We performed a median of 7 sessions of sclerotherapy. Complete resolution or improvement was observed in 48 patients presented. Five cases of small skin ulceration, two cases of hyperpigmentation and two of paresthesia were documented; all of them were treated conservatively.

CONCLUSION

Percutaneous sclerotherapy with low doses of ethanol is a safe and effective treatment modality for venous malformations affecting the head and neck.

Congenital arteriovenous malformations: A follow-up of treatment

Due to the rarity of arteriovenous malformations (AVMs), there is a paucity of information on the outcomes of various treatments. Presently, the mainstays of treatment of an AVM are embolization, surgical excision or a combination of both. A retrospective study of 26 patients with AVMs treated at The Hospital for Sick Children, Toronto, Ontario between 1985 and 1995 was performed. The treatment strategies and patient outcomes were compared in terms of efficacy, complications and the response of patients and their families to their overall treatment. The overall findings showed that embolization alone was effective in controlling symptoms, but may be associated with an increased AVM size. A partial excision of an AVM does not appear to exacerbate recurrence, as has been previously reported. In fact, even after what appears to be a complete excision of the AVM, recurrence may still occur. Complications from a surgical excision of the AVM are more frequent but less devastating than complications from embolization of the lesion. The overall patient or parent satisfaction with treatment was high with respect to improvement in outcome. It is expected that with an increasing understanding of vascular malformations, and the evolution of interventional radiological techniques, complications will decrease and results as a whole will improve.

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.

Cervicofacial hemangiomas: pattern, clinical management, and treatment outcomes

OBJECTIVE

The aim of this study was to evaluate treatment outcomes following various managements of hemangiomas.

STUDY DESIGN

Sixty-two patients were included and retrospective review conducted. Based on clinical management, each patient was assigned different treatment groups: steroid, sclerotherapy, surgical, and combined therapy. Treatment outcomes were evaluated based on improvement in size, color, and texture by a blinded panel of 4 raters including 3 doctors and 1 patient or patient's parents. Finally, comparison of outcomes between groups was analyzed.

RESULTS

The results revealed that there was reduction in size and improvement in color and texture following intervention in each group. No significant difference in outcome was observed between groups regarding change in size and texture. However, color change was better in combined and surgical treatment groups.

CONCLUSIONS

A favorable outcome can be achieved following appropriate intervention during all stages of development of hemangiomas.

Percutaneous sclerotherapy of vascular malformations in children using sodium tetradecyl sulphate: the Birmingham experience

INTRODUCTION AND AIMS

Sclerotherapy has become first line treatment for most venous malformations and some lymphatic malformations. We aimed to measure our sclerotherapy treatment success using 3% sodium tetradecyl sulphate (STD) and describe our experience.

MATERIALS AND METHODS

Retrospective five year review (Jan 04-09) of children with vascular malformations treated at our centre with 3% STD. Patients were classified using the Birmingham classification and treatment success was measured through case note review and pre- and post-treatment photographs. FINDINGS AND RESULTS: Forty-three (84.3%) of the 51 patients with vascular malformations (VM) who underwent sclerotherapy derived a benefit. Twelve patients (23.5%) had an excellent result, 31 (60.8%) were improved whilst eight (15.7%) were unchanged. Using Fisher's exact test, there was a statistically significant difference in achieving complete resolution of superficial VMs compared to lesions involving the deeper layers of the head and neck. 17.6% of patients developed a complication with an overall complication rate of 12.2% per injection. There was one major complication with the remainder consisting of superficial skin necrosis that resolved conservatively.

CONCLUSIONS

Treatment with 3% STD sclerotherapy is effective in venous and some lymphatic vascular malformations. It should be considered an important treatment modality within a multi-disciplinary setting in these difficult problems.

Suprahyoid pharyngotomy for excision of laryngeal venous malformation

We report an uncommon case of symptomatic venous malformation of the larynx in a 22-year-old man, and the successful surgical management thereof. A detailed radiologic investigation of the lesion was done, followed by surgical excision via a suprahyoid pharyngotomy using cold instruments. Long-term follow-up was maintained, and the patient had subjective and objective resolution of his symptoms and signs at 3 years postoperatively. We conclude that radiology can reveal hitherto unsuspected extensions of vascular malformations in the neck and that surgical excision is a viable mode of treatment in upper aerodigestive venous malformations.

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.

Sclerotherapy of voluminous venous malformation in head and neck with absolute ethanol under digital subtraction angiography guidance

OBJECTIVES

Venous malformation (VM) is the most common symptomatic low-flow vascular malformation, which predominantly occurs in the head and neck region. The aim of this paper was to evaluate the results of endovascular sclerotherapy of voluminous VM, when the lesion is either >or=15 cm in maximum diameter or the lesion invades more than one anatomical space, in the head and neck region using absolute ethanol under digital subtraction angiography (DSA) guidance.

METHODS

A total of 23 patients with head and neck VMs between October 2005 and December 2008 were retrospectively reviewed. All patients received direct puncture ethanol sclerotherapy under DSA guidance. Follow-up assessments were performed at 3-25 months after therapies were completed, and complications were reported in some cases.

RESULTS

All patients were satisfied with the results of therapy. Seventeen patients (73.9%) achieved excellent responses and six patients (26.1%) achieved good responses in magnetic resonance imaging assessments. Minor complications developed during the procedures, all of which were successfully managed with full recovery during follow-ups. Serious complications such as acute pulmonary hypertension, cardiovascular collapse and pulmonary embolism were not encountered.

CONCLUSION

It is concluded that sclerotherapy with absolute ethanol under DSA guidance is an important alternative therapy for voluminous and extensive VM, as the procedure is reasonably safe and offers good therapeutic results.

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.

Squamous Cell Carcinoma Arising from an Arteriovenous Malformation of the Scalp

We present the case of a 70-year-old man with a congenital scalp lesion consistent with an arteriovenous malformation (AVM) which over the last 3 years had developed ulcerative changes and bleeding in the central aspect that was a biopsy proven squamous cell carcinoma (SCCA). To control hemorrhage during surgery, a radiologist performed selective embolization of major feeding arteries in the lesion three days before the surgery. After total resection of the lesion, a scalp reconstruction was performed by using a free latissimus muscle flap and skin graft. As a result, bleeding was well controlled, the AVM and SCCA were totally resected, and satisfactory aesthetic results were obtained. This appears to be the first description of a SCCA arising from a chronic AVM. This is suggestive of a possible Marjolin's ulcer from a chronic wound bed.

Management of low-flow vascular malformations of upper aero digestive system—role of N-butyl cyanoacrylate in peroperative devascularization

OBJECTIVES

Low-flow vascular malformations of upper aero digestive system may cause difficulty in swallowing and/or breathing and bleeding from these lesions may even threaten the life of patient due to risk of aspiration. These lesions may require surgical resection with prior devascularization to minimize blood loss during surgery.

METHODS

Peroperative devascularization of vascular malformations was carried in patients of our study group by injecting N-butyl cyanoacrylate (NBCA) into vascular malformations using direct puncture technique. This was followed by surgical resection of lesion in the same sitting.

RESULTS

Successful devascularization of vascular malformations in all patients in our study group was achieved by injection of NBCA into the lesion by direct puncture technique. There was retraction of malformation due to devascularization, good plane of cleavage was found during subsequent surgical resection and blood loss was minimal.

CONCLUSIONS

Low-flow vascular malformations of upper aero digestive system can be treated with surgical resection after peroperative devascularization. Direct puncture of NBCA into lesion under fluoroscopy control is an effective, safe and inexpensive method of devascularization which can be carried out by the surgeon in a single sitting.

Hemangiomas of infancy: clinical and biological characteristics

Hemangiomas of infancy are common in the general pediatric population, are usually easily diagnosed, and generally do not require treatment. However, a small but significant percentage of hemangiomas of infancy may develop complications, including infection or ulceration. In addition, hemangiomas located in some anatomic regions may be associated with other anomalies and therefore require more careful monitoring and earlier intervention to prevent permanent sequelae. This review focuses on distinguishing hemangiomas from vascular malformations and delineates the natural history of hemangiomas of infancy, with an emphasis on identifying those hemangiomas that require additional evaluation and closer follow-up. Current treatment modalities, including the use of systemic steroids and the pulsed-dye laser, are discussed. In addition, several conditions that often present with cutaneous hemangiomas are described, including PHACES syndrome and neonatal hemangiomatosis. Finally, an assessment is made of the current understanding of the biology of hemangioma proliferation and involution, including the role of endothelial growth factors and GLUT1, a new marker for hemangiomas of infancy.

Optimal management of facial telangiectasia

Telangiectasia can be treated with many different modalities. Electrosurgery is effective but dependent on technique. Sclerotherapy can be used on larger blue telangiectasia but may be complicated from inadvertent injection into arterioles. Surgical phlebectomy can be used on reticular veins but is technically difficult. Many different laser wavelengths can be successfully used to minimize and/or eliminate vascular lesions on the face. Each type of laser has advantages unique to its profile of wavelength, pulse duration, spot size and cutaneous cooling. The benefits of using 532-595 nm lasers are the multiple applications of these lasers on treating not only telangiectasia, but also pigmentation and even fine wrinkles. Newer methods of cutaneous cooling and lengthening of pulse duration make these lasers less painful with fewer adverse effects (purpura) than previous lasers. The benefit in using a 1064 nm laser is that its longer wavelength can penetrate more deeply, allowing effective thermosclerosis of vessels up to 3-4 mm in diameter. In addition, the 1064 nm wavelength permits treatment of patients of skin types I-VI with or without a tan, since melanin absorption is minimal.

Head and neck vascular malformations: time-resolved MR projection angiography

Extracranial vascular anomalies can be divided into haemangiomas and vascular malformations. The latter can be subdivided on the basis of the predominant type of vascular channels. Separation of high- and low-flow vascular malformations is of clinical importance. We report preliminary observations on time-resolved magnetic resonance projection angiography (MRPA) of vascular malformations of the head and neck. We examined eight patients with vascular anomalies of the head and neck. On MRPA the time between the early arterial phase and enhancement of the malformation could be used to distinguish high- and low-flow lesions. High-flow arteriovenous malformations showed early, intense enhancement. Venous malformations were either not visible on MRPA or showed late enhancement of veins. One patient was examined after embolisation of an arteriovenous fistula of the mandible. Normal MRPA was taken to indicate absence of a residual lesion.

Colour duplex ultrasound-guided sclerotherapy: a new approach to the management of patients with peripheral vascular malformations

INTRODUCTION

Colour duplex ultrasound (CDU)-guided sclerotherapy is a valuable modality for treating peripheral vascular malformations (PVMs).

PATIENTS AND METHODS

Between April 1996 and October 1998, 75 patients (age 5-65 years) with PVMs were subjected to CDU. Sclerotherapy was subsequently performed on 40 patients, without sedation, using 3% sodium tetradecyl sulfate, with mean follow-up of 4 years.

RESULTS

CDU of the 33 high-flow lesions (HFLs) revealed direct arteriovenous (AV) communicating channels with very high forward diastolic flow in seven lesions (arteriovenous fistulas, AVFs), but not in the other 25 lesions (non-AVF). One was a mixed lesion picked up by CDU. Sixteen HFLs were subjected to sclerotherapy; 13 (81.25%) regressed. CDU of the 42 low-flow lesions (LFLs) helped categorize them into Type 1, where no supplying arteries could be seen (12 lesions), and Type 2, where supplying arteries were seen (30 lesions). Type 2 lesions could be further subcategorized based on the spectral trace of their supplying arteries: Type 2a, high-resistance flow (25 lesions); and Type 2b, low-resistance flow with a small forward diastolic flow (5 lesions). Twenty-four LFLs were subjected to sclerotherapy; 20 (83.3%) regressed.

CONCLUSION

CDU findings correlated well with the clinical appearances of PVMs, and helped to further subcategorize these lesions based on flow. Significant differences in the Doppler flowmetry parameters of the supplying arteries seen in the HFLs and LFLs have enabled us to suggest values for differentiating between them. CDU was also found to be valuable in the follow-up of these lesions.

Use of the direct puncture technique in management of capillaro-venous malformations: case report

BACKGROUND: Preoperative devascularization of the capillaro-venous malformations located in the aero-digestive tract is important for surgeons, to minimize blood loss during surgical excision of malformations. CASE PRESENTATION: Here we present two cases of capillaro-venous malformation in which we could successfully achieve preoperative devascularization, by directly injecting n-butyl cyano acrylate into the capillaro-venous bed. This technique is relatively easy, safe and cheap, and can be carried out immediately before surgery.

Preoperative Ethanol Sclerotherapy for Facial Cavernous Hemangioma

Ethanol injection therapy is gaining more acceptance for the treatment of vascular lesions. A case of extensive cavernous hemangioma treated with surgical resection and preoperative sclerotherapy with absolute ethanol is presented. By using magnetic resonance imaging, it was shown that ethanol injections in the vascular channels produced enough sclerosis that excisional surgery with less bleeding was possible.

In vitro and in vivo photosensitizing capabilities of 5-ALA versus photofrin in vascular endothelial cells

BACKGROUND AND OBJECTIVE

The objective of the present study was to evaluate the feasibility of photodynamic therapy (PDT) for complicated hemangiomas. The photosensitizing activities of 5-aminolevulinic acid (5-ALA) and Photofrin were evaluated in vitro with human dermal microvascular endothelial cells (MEC) and in vivo with the chicken cox comb.

STUDY DESIGN/MATERIALS AND METHODS

The in vitro absorption and photosensitizing activities of 5-ALA and Photofrin were examined in a MEC culture system. The percentages of MEC killed by different drug concentrations at a wavelength of 630 nm were measured by either live/dead or lactate dehydrogenase-released assays. Similarly, the in vivo biological activities of 5-ALA and Photofrin exposed to different total light dosages at 630 nm were studied by determining the amount of necrosis produced in chicken combs.

RESULTS

MEC incubated with 5-ALA at a concentration of 35 microg/ml and exposed to laser light at 630 nm at a power density of 100 mW/cm2 showed a 50% cell kill. MEC incubated with Photofrin at a concentration of 3.5 microg/ml and exposed to laser light at 630 nm at a power density of 100 mW/cm2 showed a 50% cell kill. Chicken combs that received 200 mg/kg of 5-ALA exposed to laser light at 630 nm at a power density of 100 mW/cm2 had an injury depth of 362.5+/-27.6 microm at histologic examination. Combs exposed to a power density of 100 or 120 mW/cm2 showed injury depths of 732.5+/-29.1 and 792.5+/-36.0 microm, respectively. Chicken combs that received 2.5 mg/kg of Photofrin exposed to laser light at 630 nm at a power density of 80 mW/cm2 had an injury depth of 535.6+/-22.3 microm at histologic examination. Combs exposed to a power density of 100 or 120 mW/cm2 showed injury depths of 795.8+/-32.5 and 805.2+/-49.1 microm, respectively.

CONCLUSION

Both 5-ALA and Photofrin have the capability to destroy MEC in vitro and vasculature in vivo. However, Photofrin achieved a higher degree of cell kill and tissue destruction at lower drug concentrations and at lower power densities.

Arteriovenous malformation of the forehead, anterior scalp, and nasal dorsum

Management of complex and relentless large arteriovenous malformations with long term control and acceptable aesthetic results can be accomplished. This outcome requires selective intra-arterial embolization, judicious surgical resection, composite reconstruction with free tissue transfer, other ancillary procedures, or both, and careful serial follow-up examinations to rule out recurrent or persistent disease.

Large arteriovenous malformations of the face: aesthetic results with recurrence control

Large facial arteriovenous malformations are problematic for patients because of grotesque disfigurement, risk of rapid enlargement, and life-threatening rupture. Successful treatment of these relentless complex lesions is one of the most difficult challenges facing plastic surgeons. From a series of 300 large facial arteriovenous malformations, 85 patients were treated with embolization and excision; six of these cases (representing six separate anatomic regions: labial, auricular, eyelid, cheek, chin, and occipitoparietal) were selected for review. The purpose of this article was to look critically at the management of these six facial arteriovenous malformations, including patient presentation, angiographic procedures, surgical planning and technique, and postoperative long-term follow-up care. Lessons learned from the six representative cases provide clues for the management of large facial arteriovenous malformations and demonstrate the possibilities of recurrence and their occasionally relentless behavior. The cases show that long-term control of these lesions with acceptable aesthetic results can be achieved. The mainstay of treatment includes the following: (1) selective intra-arterial embolization with fine catheters and direct lesional embolization; (2) judicious resection and reconstruction with local or expanded tissue flaps; and (3) careful follow-up with serial examinations, duplex, and arteriography.

Treatment of oral vascular anomalies by transfixion technique

BACKGROUND

Vascular anomalies (hemangiomas and vascular malformations) are frequently located in the oral cavity. They can be treated by cool steel surgery, cryotherapy, laser therapy, embolization, and sclerosis. The choice of treatment should depend on the type of vascular anomaly, its site, the general condition of the patient, and the doctor's experience.

OBJECTIVE

The objective of this article is to assess the usefulness, indications, and advantages of transfixion technique in the treatment of oral vascular lesions.

METHODS

We present seven patients with various vascular anomalies in the oral cavity that were treated using transfixion technique. This procedure is performed with local infiltration anesthesia and it consists of interlacing a polyglycolic acid suture a number of times in an upward direction until the vascular anomaly becomes bloodless.

RESULTS

In all seven patients we completely eliminated the vascular lesion without significant long-term complications. We detected a transitory retractil scar in only one patient and edema in the postoperative period in another one.

CONCLUSIONS

Treatment of vascular anomalies of the oral cavity by transfixion technique is an effective, simple method that does not cause major complications and is low in cost.

Laser intraductal photocoagulation of bilateral parotid ducts for reducing drooling of cerebral palsied children: a preliminary report

Previous reports suggested that surgical treatment was effective to reduce abnormal, profuse drooling in children with low cognitive function, but with risk of complications. Laser photocoagulation might be an option to simplify the procedure and decrease complications. Our study considered whether laser photocoagulation could improve drooling in children with cerebral palsy (CP). CP children with drooling were recruited from the pediatric rehabilitation clinic, all of whom had persistent profuse drooling after 6 months of conservative treatment. They received neodymium:yttrium aluminum garnet (Nd:YAG) laser for intraductal photocoagulation to bilateral parotid ducts, and were followed up for 2 to 3 months. Each patient was assessed before and after the procedure by: 1) questionnaire-based semiquantitative assessment of drooling severity and frequency (Thomas-Stonell and Greensberg 1988); 2) quantitative assessment of saliva amount by collection of stimulated saliva for 2 minutes in cooperative children. Six CP children with severe drooling received laser photocoagulation, five of them had remarkable decrease of drooling 1 month later. Patients had cool liquid intake soon after the procedure, and were discharged on the second day after treatment. A period of transient face swelling ranged from 6 to 37 days. No antibiotic treatment was indicated nor were any complications noted after the procedure. As a result of these studies, it is suggested that laser intraductal photocoagulation of bilateral parotid duct could be used as a simple and effective procedure for reducing drooling in CP children, and would avoid complications from conventional surgery.

Intralesional sclerotherapy in the management of hemangiomas of the glans penis

PURPOSE

We studied the role of sclerotherapy in the management of glans penis hemangiomas.

MATERIALS AND METHODS

Four patients with hemangiomas of the glans penis were treated on an outpatient basis with intralesional injections of 30% hypertonic saline.

RESULTS

In all 4 patients the lesions regressed and all were satisfied with the outcome.

CONCLUSIONS

Intralesional sclerotherapy is a cost-effective modality for the treatment of glans penis hemangiomas, especially in developing countries and at peripheral hospitals where expensive laser equipment may not be available.