Surgical treatment of cervicofacial cystic hygromas in children

Cervical lymphatic malformations amenable to transhairline robotic surgical excision in children: A case series

Lymphatic malformations are rare benign malformations that predominantly occur in the head and neck region. The advent of surgical robots in head and neck surgery may provide beneficial outcomes for pediatric patients. Here, we describe our experiences with transhairline incisions for robot-assisted surgical resection of cervical lymphatic malformations in pediatric patients.In this prospective longitudinal cohort study, we recruited consecutive patients under 18 years of age who were diagnosed with congenital cervical lymphatic malformations and scheduled for transhairline approach robotic surgery at a single medical center. We documented the docking times, console times, surgical results, complications, and postoperative follow-up outcomes.The studied patients included 2 with mixed-type lymphatic malformations and 2 with macrocystic-type lymphatic malformations. In all 4 patients, the incision was hidden in the hairline; the incision length was <5 cm in 3 patients but was extended to 6 cm in 1 patient. Elevating the skin flap and securely positioning it with Yang retractor took <1 hour in all cases. The mean docking time was 5.5 minutes, and the mean console time was 1 hour and 46 minutes. All 4 surgeries were completed endoscopically with the robot. The average total drainage volume in the postoperative period was 21.75 mL. No patients required tracheotomy or nasogastric feeding tubes. Neither were adverse surgery-associated neurovascular sequelae observed. All 4 patients were successfully treated for their lymphatic malformations, primarily with robotic surgical excisions.Cervical lymphatic malformations in pediatric patients could be accessed, properly visualized, and safely resected with transhairline-approach robotic surgery. Transhairline-approach robotic surgery is an innovative method for meeting clinical needs and addressing esthetic concerns.

A unique case of recurrent fetal cystic hygroma: first fetus with an inherited heteromorphism of chromosome 1 (1qh+) and the second fetus with 69XXX triploidy

The authors report a unique recurrent septated cystic hygroma (CH), on two successive pregnancies, at five years interval. The chromosome analysis of the first fetus showed an increase in length of heterochromatin on the long arm of chromosome 1 – 1qh+, a chromosomal polymorphism inherited from mother, 46XX,1qh+,14ps+,21ps+. The karyotype of the second CH, with more severe ultrasound (US) imaging, showed a 69XXX triploidy. The patient took no risk and underwent each time a termination of pregnancy (TOP). The first karyotype is generally considered “normal”, although there are few reports linking 1qh+ with low fertility, but this was not the case, the patient having, from a previous marriage, a healthy boy and two TOPs. So, this “particular”, but “healthy” karyotype was not a cause for the first CH. The second karyotype highlights a possible causality between the 69XXX triploidy, usually associated with partial hydatidiform mole, and a more severe septated CH in the last fetus. Neither the CHs’ appearance nor their recurrence seemed to be family linked, as the two CHs had distinct genetic profiles. We recommend that, once CH is diagnosed, a careful US examination is compulsory for the determination of subcutaneous edema, ascites, pleural and pericardial effusions and cardiac or renal abnormalities; an early genetic work-up is mandatory, by chorionic villus sampling or amniocentesis. However, a “healthy” karyotype does not exclude a severe form, as in our first case of CH. Due to the very poor outcome of fetuses with CH, the patient must be thoroughly informed about the short and the long-term fetal prognosis.

Recurrent Neck Lymphangioma in a Young Adult: Twenty-Three Years After Successful Treatment

Lymphangiomas are rare benign malformations of the lymphatic system, commonly present in children, over the head and neck area. Occasionally, they can grow significantly in size and especially those located over the cervical region can cause airway obstruction and become life-threatening. Recurrent lymphangiomas usually occur during the early postsurgical period and 80% of them within the first 3 to 5 years. However, in a new onset of clinical manifestations affecting the head and neck, even many years after the successful surgical treatment, a recurrent lymphangioma should be considered in the differential diagnosis. We present herein the second reported case, to our knowledge, of a recurrent left-sided neck lymphangioma in a young man, 23 years after a successful surgical treatment that initially took place 6 weeks after his birth.

Abdominal cystic lymphangioma in a term newborn: A case report and update of new treatments

INTRODUCTION

Lymphatic malformations are benign anomalies derived from the abnormal development of lymphatic channels. Usually asymptomatic, they can cause compression on adjacent structures or present acute complications (bleeding or infection). Small asymptomatic lesions can be conservatively managed since the possibility of spontaneous regressions is described, while symptomatic lesions require active management. Less invasive therapeutic options are now preferred instead of surgery (sclerotherapy, laser therapy). However, there are not uniform therapeutic protocols.

CASE REPORT

We present the case of a term newborn with an abdominal cystic lymphangioma extending from the umbilical to the right inguinal area, reaching the medial surface of the right tight. Despite its large dimensions, which classically request surgical management, the patient was by chance asymptomatic, and the mass did not determine compression on the surrounding organs. Therefore, conservative management was tried, and a close clinical and radiological follow-up was started. This approach permitted a spontaneous regression of the mass and to avoid major surgical intervention.

CONCLUSION

Our purpose is to underline the possibility of conservative management of the major multicystic masses and to focus on less invasive therapeutic options, like sclerotherapy, oral therapy, and laser therapy.

Spontaneous resolution of a recurrent axillary cystic hygroma following acute infection

We report a case of spontaneous resolution of a recurrent axillary cystic hygroma in a 4-year-old boy. He presented with a 1-year history of a cystic lump in the left axilla, which intermittently changed in size. Ultrasound suggested it was a lipoma, with raised suspicions of vascular malformation. Scans were discussed in a multidisciplinary meeting and provisional diagnosis of lymphocele or slow flow lymphovascular malformation was made. It was surgically excised and histology confirmed the lesion to be a cystic hygroma. However, it recurred within 3 weeks. The patient was booked for aspiration and treatment with sclerotic agent OK 432. He developed acute infection in the cystic hygroma a week before surgical intervention and was treated with antibiotics for 5 days by his general practitioner. Acute infection led to complete spontaneous resolution of the cystic hygroma within a week. There are no other reported cases in which recurrent cystic hygroma has resolved after a week of acute infection.

A rare case of lymphangioma in the gluteal region: surgical treatment combined with sclerotherapy and laser therapy

BACKGROUND

Lymphangioma, a rare benign malformation of lymphatic channels, is among the surgically treatable diseases of the lymphatic vessels. However, damage to surrounding structures together with incomplete resection due to adjacent organ infiltration and a high recurrence rate have encouraged the search for alternative treatments. This study aimed to identify the best therapeutic management for this difficult-to-treat disease.

METHODS

This report describes a case of congenital lymphangioma in the gluteal region in a young woman. First, sclerotherapy of the lymphangioma was performed and then surgical excision of residual lesions. Finally, as a third therapeutic step, the patient also was subjected to a cycle of laser therapy with the aim of further improving the appearance of the gluteal region. Pulsed dye laser was used to remove cutaneous dyschromias, and an erbium:yttrium-aluminum-garnet laser was used to remove surface irregularities and obtain better skin smoothness. The outcome assessments included standardized photography, the physician's global assessment, the patient's satisfaction scores, and magnetic resonance imaging of the gluteal region.

RESULTS

All the lesions of lymphangioma were removed. After the last laser treatment, the skin of the entire treated region was eutrophic and uniform in color, and it appeared to be smooth and soft when palpated. The patient was satisfied with the clinical and aesthetic results achieved.

CONCLUSIONS

The combination of sclerotherapy with surgery can be a good solution for the treatment of lymphangioma. The authors also propose laser therapy as an additional therapeutic approach that may follow surgery or sclerotherapy with the aim of improving the skin trophism and the appearance of the affected region.

Intralesional bleomycin in lymphangioma: an effective and safe non-operative modality of treatment

Introduction:

Lymphangiomas are benign hamartomatous lymphatic tumors. The mainstay of the therapy is surgical excision, but due to its infiltration along the nerves and muscles, total excision is not always possible. In the present study, we have evaluated the clinical profile of all the cases of lymphagiomas coming to our department and evaluated the efficacy of intralesional Bleomycin as a sclerosing agent in its management.

Materials and Methods:

In this prospective study, all patients were evaluated clinically and color Doppler ultrasonography (USG). The required dose was calculated as 0.5 mg/kg body weight, not exceeding 10 units at a time. The response was assessed clinically and on the basis of color Doppler USG.

Results:

Thirty-five patients of lymphangioma were included in the study. The neck region was the most common site of involvement. The response was excellent in 7 (20%), good in 26 (74.29%), and poor in 2 (5.71%) patients. The complications included fever, transient increase in size of swelling, local infection, intraluminal bleed, and skin discoloration in 10 patients.

Conclusion:

This therapy may be used as primary modality instead of surgery in selected group of patients.

Head and Neck Lymphatic Malformation Treatment

Objective

To systematically review literature pertaining to head and neck lymphatic malformation treatment and to use individual-level data presented in qualifying case series to describe the reported efficacy, complications, and functional impact of surgery and sclerotherapy. The authors evaluated whether treatment modalities differ by lymphatic malformation stage.

Data Sources

The terms lymphangioendothelioma, lymphangioma, cystic hygroma, and malformation were used to perform an Ovid literature search yielding 6292 references. The authors excluded references that did not involve head and neck lymphatic malformation treatment, include at least 5 patients, follow patients 1 year, define treatment modality, and state complications.

Review Methods

The authors summarized data from 1205 patients reported in 41 articles. Individual-level data, in the 29 articles reporting these data, were pooled and tabulated.

Results

The absence of within-study comparisons of treatment success, as well as the range of reporting methods, precluded a formal meta-analysis. Most reports were case series (37; 90%). The primary treatment modality was sclerotherapy in 17 (41%), surgery in 16 (39%), or surgery combined with other modalities in 9 (20%). Individual-level data were captured for 283 patients. No treatment modality clearly resulted in superior treatment outcome. Complications were more frequent in surgical series but were reported inconsistently in sclerotherapy studies.

Conclusion

There is evidence that lymphatic malformation treatment can be done effectively with surgery or sclerotherapy, but further study is necessary to determine which is superior. Standardized guidelines for reporting lymphatic malformation case series do not currently exist, making comparison of treatment outcomes of differing treatment modalities difficult.

Percutaneous sclerotherapy of massive macrocystic lymphatic malformations of the face and neck using fibrin glue with OK-432 and bleomycin

Picibanil (OK-432) and bleomycin have been used as alternative sclerosing agents for lymphatic malformations. This study evaluated the clinical curative effect of sclerotherapy using fibrin glue combined with OK-432 and bleomycin for the treatment of macrocystic lymphatic malformations of the face and neck. Fifteen paediatric patients (6 males; 9 females, aged 13 months to 14 years) who had received percutaneous sclerotherapy for massive macrocystic lymphatic malformations of the face and neck were retrospectively reviewed. Affected regions included the neck, parotid region and parapharynx, mouth floor, face and cheek, and orbital regions. All patients showed preoperative symptoms of space-occupying lesions between 4 cm × 5 cm and 12 cm × 16 cm in size. Fibrin glue with OK-432 and bleomycin was injected under general anaesthesia. All patients received preoperative and follow-up CT scans. Outcomes were assessed by three surgeons. All patients exhibited mid-facial swelling for 3-4 weeks after surgery, but no major complications. Follow-up periods ranged from 8 to 16 months. Eight lesions were completely involuted, five were mostly involuted, and two were partially involuted. Percutaneous sclerotherapy using fibrin glue with OK-432 and bleomycin provided a simple, safe, and reliable alternative treatment for massive macrocystic lymphatic malformations of the face and neck.

Sclerotherapy with bleomycin does not adversely affect facial nerve function in children with cervicofacial cystic lymphatic malformation

BACKGROUND AND PURPOSE

Sclerotherapy with bleomycin sulfate (BS) is currently used in the management of cervicofacial cystic lymphatic malformations in children. Neurotoxic adverse effects of BS after intraventricular or intracavitary administration have been reported; however, the effects of intralesionally administered BS on the adjacent peripheral neural structures have not been previously investigated. The authors conducted a clinical experimental study to evaluate facial nerve function in children who have undergone BS sclerotherapy for cervicofacial cystic lymphatic malformation.

MATERIALS AND METHODS

Twelve patients who underwent BS sclerotherapy for cervicofacial lymphatic malformation were included in the study. The hospital records were reviewed, and the following data were recorded: age at admission and at the time of motor nerve conduction study (MNCS) and electromyography (EMG) study, sex, time elapsed between sclerotherapy and the EMG study, and the outcome. The MNCS/EMG study was performed by neurologists blinded to the side of sclerotherapy. Bilateral facial MNCS and needle-EMG study of the orbicularis oris muscle on the treated side were performed. The previously treated and untreated sides constituted the study and control groups, respectively. In the MNCS, compound muscle action potential (CMAP) amplitude and distal latencies were recorded from the orbicularis oculi and orbicularis oris muscles on both sides, and needle-EMG of the orbicularis oris muscle was performed on the treated side.

RESULTS

The male-to-female ratio was 2, and age at the time of sclerotherapy ranged from 1 month to 16 years (median, 19.5 months). The lymphatic malformations were located in the right submandibular (n = 5), left submandibular (n = 6), and in the right buccal (n = 1) areas. Bleomycin sulfate was injected 1 to 4 times, and the time elapsed between injections varied from 1 to 6 months. The results of sclerotherapy were excellent, with residual disease observed in only 1 patient. The MNCS/EMG study was performed 6 months to 10 years after completion of sclerotherapy, and ages of the patients at the time of the study ranged from 4 to 17 years. Side-to-side CMAP amplitude difference did not exceed 50% for orbicularis oculi and orbicularis oris muscles. The mean CMAP amplitude of orbicularis oculi and orbicularis oris muscles on the treated and untreated sides (1219.0 +/- 842.0 vs 1202.4 +/- 923.8 microV and 1866.3 +/- 911.5 vs 1921.0 +/- 910.0 microV, respectively) did not differ between groups (P = .76 and P = .80). Distal latencies recorded from orbicularis oculi and orbicularis oris muscles on treated and untreated sides (2.64 +/- 0.46 vs 2.68 +/- 0.47 milliseconds and 3.10 +/- 0.35 vs 3.10 +/- 0.25 milliseconds, respectively) also did not differ between groups (P = .71 and P = .80). Needle-EMG orbicularis oris muscle (n = 11) on the treated side showed normal findings at rest, and there was no spontaneous activity. During mild voluntary contraction, the amplitude and duration of motor unit action potentials were within normal limits except in one case. Interference patterns were also normal in all cases.

CONCLUSION

Bleomycin sulfate did not adversely affect facial nerve function in children who underwent sclerotherapy for cervicofacial cystic lymphatic malformation when it was applied according to our protocol.

Lymphatic malformations: a proposed management algorithm

OBJECTIVE

The aim of this study was to develop a management algorithm for cervicofacial lymphatic malformations, based on the authors' experience in managing these lesions as well as current literature on the subject.

STUDY DESIGN AND METHODS

A retrospective medical record review of all the patients treated for lymphatic malformations at our institution during a 10-year period (1998-2008) was performed.

DATA COLLECTED

age at diagnosis, location and type of lesion, radiologic investigation performed, presenting symptoms, treatment modality used, complications and results achieved.

RESULTS

14 patients were identified. Eight (57%) male and six (43%) female. There was an equal distribution between the left and right sides. The majority (71%) of cases were diagnosed within the first year of life. The majority of lesions were located in the suprahyoid region. The predominant reason for referral was an asymptomatic mass in 7 cases (50%) followed by airway compromise (36%) and dysphagia (14%). Management options employed included: observation, OK-432 injection, surgical excision and laser therapy. In 5 cases (36%) a combination of these were used.

CONCLUSION

Historically surgical excision has been the management option of choice for lymphatic malformations. However due to the morbidity and high complication rate associated this is increasingly being questioned. Recent advances in sclerotherapy e.g. OK-432 injection have also shown significant promise. Based on experience in managing these lesions as well as current literature the authors of this paper have developed an algorithm for the management of cervicofacial lymphatic malformations.

Misleading presentation of an orbital lymphangioma

We describe a 2-year-old patient with an orbital lymphangioma who presented with massive proptosis. We highlight the importance of magnetic resonance imaging in evaluating such patients, because physical examination can be misleading. We also demonstrate the difficulties of managing recurrent hemorrhages when only subtotal excision is possible, as is frequently the case.

Cystic hygroma: characterization by computerized tomography

Lymphangiomas are benign nonencapsulated lesions composed of sequestered noncommunicating lymphoid tissue lined by lymphatic endothelium and are thought to be caused by congenital obstruction of lymphatic drainage. They are subclassified by vessel size, such as the capillary, which is rare and located in subcutaneous tissue, cavernous (located about the mouth and tongue), and cystic (cystic hygromas). The cystic hygromas show a predilection for the neck (75%) and maxilla (20%), and the remaining 5% arise in rare locations such as the mediastinum, retroperitoneum, bone, kidney, colon, liver, spleen and scrotum. Only 3%-10% of neck lesions extend into the mediastinum. In this paper, we report a rare case of cystic hygroma with a huge dimension discussing the use of computed tomography scanning for diagnosis.

[Cystic cervicofacial lymphangioma in children in Gabon]

OBJECTIVES

To review the etiopathogenesis, diagnosis, and the role of surgery in the management of childhood cystic cervicofacial lymphangioma in Gabon.

MATERIAL AND METHODS

Our retrospective study concerned 16 cases of childhood cystic cervicofacial lymphangioma treated surgically between 1990 and 2004.

RESULTS

The sample included ten girls and six boys whose average age was 30.2 months. The cystic lymphangioma was seen at birth in seven cases. It was discovered before 2 years in eight cases and after 2 years in eight cases. Two of these latter eight cases were a recurrence after previous surgery. The tumor was localized in the cervical are in ten cases, the jugal area in three cases, one of which was extended to the parotidis, the submandibular area in two cases, and the lower labial area in one case. The surgical indication was based on the clinical examination in six cases and on imaging in ten cases. The resection was considered complete in 14 cases and incomplete in two cases. In two cases, the resection was difficult, because the lymphangioma adhered to the internal jugular vein and rolled the higher laryngeal nerve and the carotid junction. The early complications were lymphoedema associated with facial paralysis (one case) and respiratory distress (one case), hematoma associated with facial paralysis (one case), lymphorrhea (one case), and a paralysis of the chin branch of the facial nerve (one case). The functional and aesthetic after-effects were marked by the persistence of facial paralysis and the existence of jugal bud flesh. The jugal (one case) and labial (one case) recurrence were discovered within 6 and 9 months after the surgery. In these two cases, there were capillary lymphangiomas. None of the patients died.

CONCLUSION

Cystic cervicofacial lymphangioma is a particular aspect of surgical pathology in children in Africa. Despite the advent of sclerosing products, surgery remains the treatment of choice in this context.