Arteriovenous Malformations of the Tongue: A Spectrum of Disease

Individualized treatment of congenital vascular malformations of the tongue

BACKGROUND/OBJECTIVE

Oral malformations of the tongue are exceedingly rare. The aim of this study was to evaluate the effectiveness of individualized treatment for patients with vascular malformations of the tongue.

METHODS

This retrospective study is based on a consecutive local registry at a tertiary care Interdisciplinary Center for Vascular Anomalies. Patients with vascular malformations of the tongue were included. Indications for therapy of the vascular malformation were macroglossia with the impossibility to close the mouth, bleeding, recurrent infection and dysphagia. Size regression of the malformation (volume measurement) and symptom improvement were investigated.

RESULTS

Out of 971 consecutive patients with vascular malformations, 16 patients suffered from a vascular malformation of the tongue. Twelve patients had slow-flow malformations and 4 fast-flow malformations. Indications for interventions were bleeding (4/16, 25%), macroglossia (6/16, 37.5%), and recurrent infections (4/16, 25%). For two patients (2/16, 12.5%), there was no indication for intervention due to absence of symptoms. Four patients received sclerotherapy, 7 patients Bleomycin-electrosclerotherapy (BEST) and 3 patients embolization. Median follow-up was 16 months (IQR 7-35.5). In all patients, symptoms had decreased after two interventions at a median (IQR 1-3.75). Volume reduction of the malformation of the tongue was 13.3%(from median 27.9 cm3 to median 24.2 cm3, p = 0.0039), and even more pronounced when considering only patients with BEST (from 86 cm3 to 59.1 cm3, p = 0.001).

CONCLUSION

Symptoms of vascular malformations of the tongue are improved after a median of two interventions with significantly increased volume reduction after Bleomycin-electrosclerotherapy.

Arteriovenous Malformation of the Tongue Resulting in Recurrent Severe Hemorrhage in a Young Dog

An 8 mo old male entire beagle was presented to the emergency and critical care service following several severe bleeding episodes from the oral cavity. Oral examination revealed a purple, spongy, pulsatile lesion on the rostral two-thirds of the tongue. Computed tomography angiography revealed a severely distended right linguofacial vein with numerous, tortuous branching vessels within the tongue, consistent with an arteriovenous (AV) malformation. A cervical surgical approach was performed, and the right lingual artery was isolated and catheterized. A direct arteriogram confirmed this was the main feeder artery to the lesion, and it was ligated. Although the bleeding episodes initially resolved, a moderate bleeding episode occurred 6 days postoperatively, and a partial glossectomy was performed. Histopathology was consistent with an AV malformation. The dog had a good recovery from surgery and remains free of clinical signs 13 mo later. Following extensive review of the veterinary literature, this is the only reported case of a lingual AV malformation in the dog. Partial glossectomy resulted in resolution of the clinical signs and was well tolerated. Although rare, AV malformations should be considered as a differential diagnosis for spontaneous oropharyngeal bleeding.

Japanese clinical practice guidelines for vascular anomalies 2017

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Update on extracranial arteriovenous malformations: A staged multidisciplinary approach

Arteriovenous malformations (AVMs) are vascular lesions that are thought to arise from congenital errors during development of vessels resulting in abnormal connections between arteries and veins. Though most AVMs develop in the brain or spinal cord, they can occur anywhere in the body. These extracranial or peripheral AVMs have a predilection for the head, neck, and limbs. Since these malformations infiltrate normal soft tissue, management requires selective treatment with preservation of normal surrounding architecture. Therefore, they are best addressed through a staged multimodal and multidisciplinary approach, using a combination of different laser, interstitial, intravascular and surgical techniques to specifically target anomalous vessels. The goal of treatment is overall disease improvement and symptom control with interventions that do not result in outcomes worse than the disease itself. Recently, the discovery of somatic and germline mutations in peripheral AVMs have contributed to a better understanding of the pathophysiology, resulting in promising new pharmacologic treatments. Recent evidence suggests that adjuvant medical therapy can enhance and sustain interventional and/or surgical outcomes. Herein we describe how a new understanding of the etiology and physiology of extracranial AVM provides guidance to current treatment approaches.

Sonography of abdominal wall vascular malformation: a case report and review of the literature

Vascular anomalies are classified as vascular tumors (VT) and vascular malformations (VM). VTs are divided according to their clinical behavior, while VMs are classified according to their flow characteristics, histopathologic features, and associations with other anomalies. Sonography emerges as the diagnostic imaging method of first choice for assessing abdominal wall disorders and masses, thus representing a valuable tool for the diagnosis and follow-up of abdominal wall VMs. In this review, we report a case of abdominal wall arteriovenous malformation (AVM) in a 17-year old and briefly discuss the cases of abdominal wall VMs.

Superselective Arterial Embolization of Arteriovenous Malformation of Internal Pudendal Artery, a Rare Cause of Hematuria: A Case Report

Arteriovenous malformation (AVM) is a common form of vascular malformation, an abnormal direct communication between an artery and a vein without passing through the capillaries. AVM may just present as hematuria without plain or other symptoms. The article presents a case of a 52-year-old male with gross hematuria diagnosed as AVM of internal pudendal artery, which was successfully managed with superselective arterial embolization using temporary embolization materials.

Japanese Clinical Practice Guidelines for Vascular Anomalies 2017

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety and systematizing treatment, employing evidence‐based medicine techniques and aimed at improvement of the outcomes. Clinical questions (CQ) were decided based on the important clinical issues. For document retrieval, key words for published work searches were set for each CQ, and work published from 1980 to the end of September 2014 was searched in PubMed, Cochrane Library and Japana Centra Revuo Medicina databases. The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System technique. A total of 33 CQ were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence‐based guidelines for the management of vascular anomalies.

Japanese clinical practice guidelines for vascular anomalies 2017

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Lymphangioma of the Dorsal Tongue

Lymphangiomas are rare, congenital malformations of the lymphatic system which have a marked predilection for the head and neck. In this region, they most commonly occur on the dorsum of the tongue, followed by the lips, buccal mucosa, soft palate, and floor of the mouth. Lymphangiomas of the tongue are commonly present at birth; however, they may go unnoticed until after eruption of the dentition or even puberty. They may present as a defined mass or as macroglossia with impaired speech, difficulty in mastication, and, in extreme cases, airway obstruction. Clinically, lymphagiomas of the tongue are characterized by clusters of pebbly, vesicle-like nodules. A benign proliferation of lymphatic vessels is identified histologically. A classic case of a lymphangioma of the dorsal tongue is presented.

Two Cases of Lingual Arteriovenous Malformations with Comorbidities Treated by Glue Embolization: A Report with Review of Literature

Arteriovenous malformations (AVMs) involving the tongue are uncommon lesions in the head and neck region. They present with bleeding that can be massive and life-threatening apart from debilitating symptoms of pain, ulcers, difficulty in phonation or swallowing. Various therapeutic approaches have been used in their management-surgery, endovascular embolization, radiation and ablation procedures like laser ablation. We report two patients-a 34 year-old man and 56 year-old female who presented with massive bleeding due to lingual AVM and had comorbidities as liver cirrhosis and chronic medical renal disease respectively, and treated with glue embolization, with a review of the literature.

Classification and Pathology of Congenital and Perinatal Vascular Anomalies of the Head and Neck

Accurate histopathologic description in correlation with clinical and radiological evaluation is required for treatment of vascular anomalies, both neoplastic and malformative. It is important to examine current clinical, histologic, and immunophenotypical features that distinguish the major types of congenital and perinatal vascular anomalies affecting the head and neck. General discussions of pathogenesis and molecular diagnosis must also be taken into account. This article provides an overview of the features that distinguish the major types of congenital and perinatal vascular anomalies affecting the head and neck, and summarizes the diagnostic histopathologic criteria and nomenclature currently applied to these lesions.

Transarterial Embolization and Transmucosal Sclerotherapy That Led to Successful Deliveries in a Patient With Symptomatic Arteriovenous Malformation of the Tongue

Patients with arteriovenous malformations (AVMs) are at risk of significant hemorrhage and AVMs are especially difficult to manage in those desiring future pregnancy. Few patients with successful deliveries have been previously reported.The authors report an unusual case of AVM of the tongue in a pregnant woman who presented with massive pulsatile bleeding from a ruptured artery in the tongue in late gestation, this was thought to be caused by the changes in hormonal balance and the increase in cardiac output. The bleeding was controlled with transarterial embolization and transmucosal absolute ethanol sclerotherapy. Furthermore, her second and third deliveries were successfully managed.The authors managed symptomatic tongue AVM by combining transarterial embolization and transmucosal sclerotherapy, which was followed by successful deliveries. This patient supports the utility of transmucosal absolute ethanol sclerotherapy for tongue AVM and multidisciplinary medical care for a successful delivery.

Arteriovenous malformations in the differential diagnosis of palatal swellings

An arteriovenous malformation (AVM) is composed of abnormal communications between arteries and veins without the normal intervening capillary bed. AVM of the head and neck is a rare vascular anomaly. We present here an unusual case of AVM with the size of 4x3 cm at the left posterior palatal area. Incisionel biopsy revealed AVM. Resection of the lesion following angiography was suggested to the patient however, he refused the treatment. The patient was considered to be under control. AVM should always be kept in mind in the differential diagnosis of palatal swellings.

Arteriovenous malformations

Arteriovenous malformations (AVMs) are fast-flow vascular malformations composed of a complex vessel network directly connecting feeding arteries to draining veins. The intervening normal capillary network is absent. Proper diagnosis and treatment of AVMs is challenging and in need of an interdisciplinary team of experienced physicians. Careful analysis of the clinical features and evaluation of therapeutic options represent the basis for successful management of AVMs. This article will focus on the clinical and radiological findings and in particular on interdisciplinary management strategies of AVMs including minimally invasive endovascular and surgical treatment.

Life-threatening bleeding after tooth extraction due to vascular malformation: a case report and literature review

Severe hemorrhages of the oral cavity may be caused by arteriovenous malformations. This case report concerns a 52-year-old healthy female who presented with a painful lower third molar and an extensive arteriovenous high-flow malformation of the floor of the right side of the mouth. During the extraction of the right lower wisdom tooth, an episode of massive life-threatening bleeding occurred. Since the therapy for intraoral arteriovenous malformations of the soft tissue is complex and often difficult to perform, the modus operandi of the present case is presented, and a review of the literature is included.

A xenograft animal model of human arteriovenous malformations

Background

Arteriovenous malformations (AVMs) are a type of high-flow vascular malformations that most commonly occurs in the head and neck. They are present at birth but are usually clinically asymptomatic until later in life. The pathogenesis of AVMs remains unclear and therapeutic approaches to AVMs are unsatisfied. In order to provide a tool for studying the pathogenesis and therapies of this disease, we established and studied a xenograft animal model of human AVMs.

Methods

Fresh human AVMs specimens harvested from 4 patients were sectioned (5x5x5 mm) and xenografted subcutaneously in 5 immunologically naïve nude mice (Athymic Nude-Foxn1^nu). Each mouse had four pieces specimens in four quadrants along the back. The grafts were observed weekly for volume, color and texture. The grafts were harvested at every 30 days intervals for histologic examination. All grafts (n = 20) were sectioned and stained for hematoxylin and eosin (H&E). Comparative pathologic evaluation of the grafts and native AVMs were performed by two blinded pathologists. Immunohistochemical examination of human-specific nuclear antigen, vascular endothelial growth factor receptor-2 (VEGFR-2) and Ki-67 was performed.

Results

Clinical characteristics and pathologic diagnosis of native human derived AVMs were confirmed. 85% (n = 17) of AVM xenografts survived although the sizes decreased after implantation. Histological examination demonstrated numerous small and medium-size vessels and revealed structural characteristics matching the native AVMs tissue.76.5% (n = 13) of the surviving xenografts were positive for Ki-67 and human-specific nuclear antigen suggesting survival of the human derived tissue, 52.9% (n = 9) were positive for VEGFR-2.

Conclusions

This preliminary xenograft animal model suggests that AVMs can survive in the nude mouse. The presence of human-specific nuclear antigen, VEGFR-2, and Ki-67 demonstrates the stability of native tissue qualities within the xenografts.

Hemangiomas and vascular malformations: current theory and management

Vascular anomalies are a heterogeneous group of congenital blood vessel disorders more typically referred to as birthmarks. Subcategorized into vascular tumors and malformations, each anomaly is characterized by specific morphology, pathophysiology, clinical behavior, and management approach. Hemangiomas are the most common vascular tumor. Lymphatic, capillary, venous, and arteriovenous malformations make up the majority of vascular malformations. This paper reviews current theory and practice in the etiology, diagnosis, and treatment of these more common vascular anomalies.

Interstitial PDT for vascular anomalies

INTRODUCTION

Photodynamic therapy is a proven therapeutic modality in the management of variety of pathologies involving the human body. Our aim in this clinical study is to prospectively evaluate the outcome following interstitial photodynamic therapy for patients with vascular anomalies. Patients' reports on quality of life with clinical and radiological evaluation were the main end point parameters used to assess the outcome.

MATERIALS AND METHODS

Forty-three patients were referred to the UCLH Head and Neck Centre for treatment of vascular anomalies of the head and neck, including: infantile and congenital haemangiomas, venous, lymphatic and arteriovenous malformations. After multidisciplinary discussion, all patients underwent interstitial photodynamic therapy under general anaesthesia, using 0.15 mg/kg mTHPC as the photosensitising agent. Following treatment, patients were followed-up for a mean of 21 months.

RESULTS

Fifteen out of nineteen patients who presented with long-term pain reported improvement after treatment. Also, 7/8 reported significant reduction of bleeding related to their vascular anomaly. Improvement of swelling was reported by 28/35 patients; while reduction of infection episodes was evident in 8/11 patients and 31/36 reported reduction in the disfigurement caused by their pathology. Significant reduction of swallowing problems was reported in 9/12 patients, and breathing problems in 7/9 patients. Clinical assessment showed that half of the patients had 'good response' to the treatment. Moderate clinical response was reported by 13 (30.2%) patients. Radiological assessment comparing imaging 6-week post-PDT to the baseline showed moderate response in 11 (25.6%) patients and significant response in 15 (34.9%) patients.

CONCLUSION

This study on 43 patients with vascular anomalies undergoing interstitial photodynamic therapy provided evidence that PDT is a successful modality in the management of these pathologies that are resistant to conventional modalities, with minimal side effects.

Treatment guideline for hemangiomas and vascular malformations of the head and neck

Vascular anomalies are among the most common congenital and neonatal dysmorphogenesis, which are separated into hemangiomas and vascular malformations. They can occur in various areas throughout the body, with 60% being located in the head and neck. The true mechanism of pathogenesis of vascular anomalies is still unclear. Various treatment methods have been reported, and there are still controversies over the selection of different treatment modalities. Based on the clinical and basic research and current literature, the Chinese Division of Oral and Maxillofacial Vascular Anomalies formulated a treatment guideline for hemangiomas and vascular malformations of the head and neck, which will be modified and updated periodically based on new medical evidence and research.

Update on pediatric extracranial vascular anomalies of the head and neck

PURPOSE

Vascular anomalies most frequently present at birth or in early childhood, and the craniofacial region is the most common site of involvement. A long history of misleading nomenclature born of confusion about the presentation and natural history of various vascular anomalies has made appropriate diagnosis difficult. The present article emphasizes the importance of clarity of nomenclature for proper diagnosis, both clinically and radiographically, to guide appropriate therapy. In addition, updates on clinical concepts, imaging, and treatment strategies will be discussed. Pediatric vascular anomalies can be divided into two broad categories: vascular tumors and vascular malformations. This biologic classification is based on differences in natural history, cellular turnover, and histology. An updated classification was introduced in 1996 by the International Society for the Study of Vascular Anomalies (ISSVA) to include infantile hemangioma variants, other benign vascular tumors, and combined lesions. Widespread confusion propagated throughout the literature and in clinical practice stems from the continued improper use of many of the terms used to describe vascular tumors and malformations ignoring their pathophysiology. This leads to errors in diagnosis and the dissemination of misinformation to patients and clinicians. Certain terms should be abandoned for more appropriate terms. The clinical presentation usually identifies what general type of vascular anomaly is present, either vascular tumor or vascular malformation. Imaging provides crucial information about the initial diagnosis and aids in follow-up.

CONCLUSIONS

Adoption and use of uniform nomenclature in the ISSVA classification system is the first vital step in correct diagnosis and treatment of often complicated vascular tumors and vascular malformations. A multidisciplinary team approach is necessary to provide optimal care for patients, and the necessity for specialists in all areas to communicate using standardized terminology cannot be overemphasized.

Plunging arteriovenous malformation in the floor of the mouth: a case report

An arteriovenous malformation (AVM) is composed of abnormal communications between arteries and veins without the normal intervening capillary bed. An 11-year-old male presented with a painless, doughy submandibular mass. Surgical excision was performed through an intraoral approach; the mass and the surgical field, did not exhibit any significant intraoperative bleeding typical of vascular lesions. Histopathological examination of the specimen revealed a diagnosis of an AVM, with the presence of organizing thrombi within arteries and veins. These abundant thrombi, previously unreported in the arterial part, may explain the negligible intraoperative bleeding.

Clinical course of arteriovenous malformations of the head and neck: A case series

Objective: To demonstrate, in a case series, the relentless growth of arteriovenous malformations (AVMs) of the head and neck and the importance of their vigilant management within the context of a modified staging system.

Study Design: Retrospective review.

Setting: Tertiary care institution, Vascular Anomalies Center.

Subjects and Methods: Subjects were patients with advanced AVMs presenting to our Vascular Anomalies Center. Medical records were examined for age at first diagnosis, disease course, prior treatments, age at presentation, management, therapeutic outcomes, stage of disease, and impact on quality of life. Early patient photographs were evaluated.

Results: Ten patients (ages 13-46 yrs) with extensive cervicofacial AVMs were examined. Progressive growth, worsening symptoms, and graduated disease stage were universally experienced by each patient, as evident by serial photographs, over a course of many years. Each patient presented to our institution with massive lesions, bleeding, pain, and facial destruction. Prior embolization and/or surgery had been performed in all but one patient. Every patient had been previously told that their AVMs were incurable or that treatment options were exhausted. The patients were subsequently treated at our institution with surgical resection with or without preoperative embolization. Disease control, symptom improvement, and enhanced daily functioning were attained in each patient.

Conclusion: The natural course of AVMs is progressive, invasive, and destructive. Vigilant observation, early treatment, and radical therapy are necessary for AVMs of the head and neck.