[Epistaxis-overview and current aspects]

Nosebleeds (epistaxis) are usually minor. Medical intervention is only necessary in about 6% of cases. The source of bleeding is frequently located in the anterior region of the nose (Kiesselbach's plexus). The estimated lifetime prevalence of epistaxis is 60%. Diffuse epistaxis is often a manifestation of systemic disease. Epistaxis is the leading symptom of Rendu-Osler-Weber disease (hereditary hemorrhagic telangiectasia, HHT). If intervention is required, the first-choice of treatment is bidigital compression for several minutes. Common therapeutic measures include local hemostasis using electrocoagulation or chemical agents, e.g., silver nitrate. Resorbable anterior nasal tampons or tampons with a smooth surface are also frequently employed. In case of failed surgical closure of the sphenopalatine artery, angiographic embolization is the method of choice.

Virome Analysis Reveals No Association of Head and Neck Vascular Anomalies with an Active Viral Infection

BACKGROUND/AIM

Vascular anomalies encompass different vascular malformations [arteriovenous (AVM), lymphatic (LM), venous lymphatic (VLM), venous (VM)] and vascular tumors such as hemangiomas (HA). The pathogenesis of vascular anomalies is still poorly understood. Viral infection was speculated as a possible underlying cause.

MATERIALS AND METHODS

A total of 13 human vascular anomalies and three human skin control tissues were used for viral analysis. RNA derived from AVM (n=4) and normal skin control (n=3) tissues was evaluated by RNA sequencing. The Virome Capture Sequencing Platform for Vertebrate Viruses (VirCapSeq-VERT) was deployed on 10 tissues with vascular anomalies (2×AVM, 1×HA, 1×LM, 2×VLM, 4×VM).

RESULTS

RNA sequencing did not show any correlation of AVM with viral infection. By deploying VirCapSeq-VERT, no consistent viral association was seen in the tested tissues.

CONCLUSION

The analysis does not point to the presence of an active viral infection in vascular anomalies. However, transient earlier viral infections, e.g. during pregnancy, cannot be excluded with this approach.

Retrospective analysis of laser vs other therapeutic modalities for laryngeal papillomatosis: European multicenter study

PURPOSE

Laryngeal papillomatosis can be an aggressive and potentially life-threatening disease, affecting both children and adults. Local excision is the gold standard of treatment, but recurrences are frequently inevitable. The purpose of this study was to present the experience of three institutions with different therapeutic modalities and discuss them in relation with the relevant literature.

METHODS

Sixty patients underwent papilloma resection during the last decade in three institutions (Homburg/Saar and Marburg, Germany and Athens,Greece). Patient data were retrospectively analyzed for therapeutic modalities applied, rate of complications and synechia formation, necessary operations and need for tracheostomy.

RESULTS

Carbon dioxide laser therapy was the most common modality applied alone or combined with other treatment modalities. No major complication was observed, while glottic synechia was the most common minor complication in 5 (8.3%) patients. Of the patient cohort 55.6% required reoperation, while no patient required tracheostomy.

CONCLUSIONS

Surgical debulking with or without adjuvant treatment remains the mainstay of treatment, which mainly aims to reduce the number and frequency of recurrences since no definitive curative therapy is known so far.

Smell and taste in patients with vascular malformation of the extracranial head and neck region

BACKGROUND

Olfactory and gustatory functions have not been investigated in patients with vascular malformation of the extracranial head and neck region with validated smell and taste tests. Although olfactory and gustatory deficiencies are often not outwardly apparent, they substantially affect daily life.

METHODS

Smell and taste tests using sniffin sticks and taste strips were administered in 40 patients.

RESULTS

For all age groups and both sexes, odor threshold (THR) values were, on average, lower in patients than in healthy individuals; whereas, values of odor identification and discrimination were not significantly lower. Regarding odor THR, 33 (82.5%) patients were hyposmic. Taste values (sweet, sour, salty, bitter, and total taste) were, on average, lower in patients than in healthy individuals; 21 (52.5%) patients were hypogeusic. Disease duration did not correlate with smell and taste test values. Patients with and without tongue involvement had decreased odor threshold and taste values. No significant differences were identified when taste values on the left and right sides of the tongue were compared in patients without tongue involvement and with unilateral and bilateral tongue involvement. Patients with venous malformations had lower smell test values, and patients with lymphatic malformations had lower taste test values than patients with other malformations.

CONCLUSION

Patients exhibit significantly reduced olfactory and gustatory function even when the nose and/or tongue are not malformed. Patients should be tested with validated smell and taste tests to adequately inform and advise them about overcoming smell and taste deficits.

Extracranial vascular malformations (hemangiomas and vascular malformations) in children and adolescents - diagnosis, clinic, and therapy

The field of extracranial vascular anomalies is considered as special focus of pediatric otolaryngology and it has shown a rapid development during the last years. The reason for this interest is finally also due to the global acceptance of the classification introduced by the ISSVA (International Society for the Study of Vascular Anomalies). Hemangiomas are the most frequently observed vascular tumors. Today the systemic propranolol therapy is mostly used for therapy of hemangiomas requiring treatment. Increasingly, the topical application of beta blocker is discussed while the benefit in the head and neck seems to be limited. Vascular malformations are classified according to the morphology of the affected part of the vascular system in arterial, venous, arterio-venous, lymphatic, capillary, and combined vascular malformations. Conventional surgery, sclerosing therapy, and laser treatment are invasive options for the treatment of lymphatic malformations. The options for the treatment of venous malformations could be significantly improved during the last years. In this context, the use of Nd:YAG laser, the conservative treatment of the localized disseminated intravascular coagulation with low-molecular weight heparin, the re-discovery of bleomycin as effective sclerosing agent, and the improvement of alcohol-based embolization agents must be mentioned. Today the treatment with dye laser is the preferred therapy for capillary malformations and it is superior to other therapeutic options as for example photodynamic therapy. Arterio-venous malformations as representatives for high-flow lesions are the high-risk lesions. Frequently they are compared to malignant head and neck tumors, in particular when a curative treatment can no longer be assured because of diffuse or multifocal extent and when the disease shows a progressive course. The combined treatment of embolization and surgical resection and if necessary consecutive defect reconstruction have turned out to be appropriate for arterio-venous malformations. Incurable findings are still a major challenge. Despite the introduction of antiangiogenetic drugs in oncology, the medicamentous therapeutic approach could not be established for arterio-venous malformations up to now.

[Lymphatic malformations in the head and neck region. Clinical aspects and therapeutic options]

Lymphatic malformations are congenital abnormalities of the lymphatic system which occur predominantly in the head and neck region. According to their dominant clinical and morphological characteristics, these are classified into micro- and macrocystic forms. Established therapies for lymphatic malformations include conventional surgery, sclerotherapy and laser treatment. Despite the significant improvements in therapeutic options seen in recent years, treatment of extensive lymphatic malformations remains an interdisciplinary challenge. Close-knit interdisciplinary cooperation is necessary to provide optimized care for affected individuals.

Localization and treatment of lingual venous and arteriovenous malformations

Venous and arteriovenous malformations of the tongue can cause haemorrhage, airway obstruction, difficulties in chewing and swallowing, speech problems as well as orthodontic abnormalities. The purpose of the present study was to evaluate their exact topography, clinical features, morphologic aspects and management. A retrospective review on all patients with venous and arteriovenous malformations of the tongue who presented between 1998 and 2010 was performed. Medical records were analysed with respect to age and sex distribution, exact localization, symptoms and clinical presentation, management and treatment outcome. Forty-four patients with tongue malformations were analysed. The malformations affected all areas of the tongue as well as the base of the tongue without predilection areas. Nd:YAG laser and CO2 laser therapy provided good results primarily in localized malformations, while in advanced malformations the management was multi-modal since a complete surgical excision was often impossible. The hypothesis that vascular malformations of the tongue occur more frequently along the course of the feeding vessels cannot be confirmed. The therapeutic approach is determined by the exact topography, haemodynamic properties, morphologic aspects and related clinical symptoms as well as patient-specific features.

[Venous and arteriovenous malformations in the head and neck region. Therapeutic options and challenges]

Venous malformations are the prototype low-flow malformations in the head and neck region. Arteriovenous malformations (AVM) represent the main high-flow malformations. In recent years it has been possible to significantly optimize the therapeutic options for venous malformations. In addition to conventional surgery, laser treatment and sclerotherapy have become established techniques and the importance of embolization with new alcohol-based materials is increasing. AVM are progressive and destructive diseases. Therapy of choice is usually a combined treatment comprising embolization and surgical removal of the arteriovenous nidus. This curative approach is usually possible if diagnosis is made at an early stage. Incomplete embolization or sole ligation of the arterial supply causes progression. There is a clear need for improved therapeutic methods and pharmacotherapeutic approaches.

The chorioallantoic membrane assay is a promising ex vivo model system for the study of vascular anomalies

The present feasibility study evaluated the chorioallantoic membrane (CAM) assay established in cancer and angiogenesis research as a tool for the study of vascular anomalies (VAs) in the head and neck area, since the lack of appropriate model systems poses a major obstacle in VA research.

MATERIALS AND METHODS

VA tissues from three patients, two with an arteriovenous and one with a lymphatic malformation, were analyzed and evaluated in the CAM assay.

RESULTS

The arteriovenous malformations induced a potent angiogenic reaction, resulting in new vessel growth and reperfusion by chicken embryo blood, which was comparable in extent with the positive vascular endothelial growth factor control. An angiogenic reaction, although less pronounced, was also observed in the single-tested lymphatic malformation.

CONCLUSION

Our observations indicate the CAM assay to be a suitable model system for the study of VAs, as well as to show how treatment with pro- and antiangiogenic drugs affects VA growth patterns. The CAM assay has the potential to become a valuable tool for VA studies.

Human papilloma virus (HPV) is not implicated in the etiology of Warthin's tumor of the parotid gland

CONCLUSION

The lack of human papilloma virus (HPV) sequences as well as potential HPV-activated cells such as cells that would be p16- and Ki-67 positive does not support a role of HPV in the pathogenesis of this lesion.

OBJECTIVE

The exact etiopathogenesis of Warthin's tumor of the parotid gland is still unclear. The aim of the present study was to evaluate if HPV could play a role in the development of this parotid lesion.

METHODS

Tissue samples from 40 Warthin's tumors of the parotid gland were investigated by PCR followed by in situ hybridization. The immunohistochemical expression of p16 and the dual immunostaining of p16 and Ki-67 were evaluated in all samples.

RESULTS

Strong and diffuse p16 immunoreactivity was found in 7 of the 40 cases (17.5%). In situ hybridization showed a diffuse episomal signal in those samples. However, PCR could not reliably detect the presence of HPV genes. Furthermore, p16-expressing epithelial cells were mostly negative for the proliferation marker Ki-67.

Phleboliths from venous malformations of the head and neck

Objectives/Hypothesis

Phleboliths in venous malformations (VM) of the head and neck are often observed and may cause significant symptoms. Only a few articles refer to the morphology and composition of the phleboliths in VM. The objective of this study was to analyse and to demonstrate their composition and morphology.

Methods

Patients with VM presenting to a vascular anomalies centre during a three-year period were identified. The incidence of phleboliths was analysed followed by morphological and structural analysis with cone beam tomography and X-ray diffraction.

Results

Phleboliths were identified in 28/98 patients with VM of the head and neck. Seven patients underwent conventional surgery to reduce the volume of the VM or to remove the phleboliths, which were localized in the cheek (3 cases), submandibular region (2 cases), infrahyoidal neck or upper eyelid (1 case each). The structural analysis showed that more advanced lamination and an increasing radiopacity of the cortex was observed in larger phleboliths. X-ray powder diffraction analysis revealed that the main constituent in the pulverized phleboliths was carbonate-fluorohydroxylapatite.

Conclusion

This study shows in a vivid way that phleboliths from VM of the head and neck area show a laminar structure and consist of apatite, without any indication of differences in their chemical composition. Treatment of localized intravascular coagulopathy in VM might be able to prevent the formation and the progression of phleboliths. Hypothetically, another option might be lithotripsy.

[Intracochlear electrode position: evaluation after deep insertion using cone beam computed tomography]

INTRODUCTION

Due to the increasing number of cochlear implantations (CI), postoperative radiological verification of the electrode position, e.g., with respect to quality control, plays a central role. The aim of this study was to evaluate the intracochlear position of deep inserted electrodes by cone beam computed tomography (CBCT).

MATERIALS AND METHODS

CBCT data sets (Accu-I-tomo, Morita, Kyoto, Japan) of 22 patients (28 ears operated between 2008 and 2011) were retrospectively analyzed. All patients underwent a CI (round window approach) with deep insertion of the electrode (Flex soft or standard electrode from MedEl©). CBCT data were analyzed for intracochlear position of the electrode (scala vestibuli, scala tympani, malposition between the scalae) and the certainty of this evaluation.

RESULTS

All ears could be evaluated with the status certain or relatively certain in the basal turn of the cochlea. Thereby, the electrode array was inserted into the scala tympani in 93% (n = 26). Primary insertion into the scala vestibuli and the scala media was observed in 3.5% of the ears, respectively. In the apical part of the cochlea, only 32% (n = 9 ears) could be evaluated with relative certainty. The remaining 68% of cases could not be evaluated. Of the 32% interpretable cases in the apical part of the cochlea, 25% (n = 7) were inserted into the scala tympani, 3.5% (n = 1) into the scala vestibuli, and 3.5% (n = 1) were malpositioned between the scalae.

CONCLUSION

The exact evaluation of the intracochlear position of the electrode by CBCT is only possible in the basal turn of the cochlea. In deep insertion, determination of the position in the medial and apical parts of the cochlea by CBCT is still not possible. Furthermore, the round window approach allows reliable implantation into the scala tympani.

Does Hereditary Hemorrhagic Telangiectasia Affect Olfactory or Gustatory Function?

Background

The olfactory and gustatory functions of hereditary hemorrhagic telangiectasia (HHT) patients have not been documented by validated tests. Disorders of the nasal/oral cavity may interfere with the olfactory and gustatory functions. Fifty-four HHT patients were investigated by smell/taste tests.

Methods

HHT patients provided subjective ratings in areas such as ability to perceive smell/taste. “Sniffin’ Sticks” were used for smell tests, and taste strips were used for taste tests.

Results

HHT patients rated their subjective olfactory and gustatory function on a visual analog scale from 0 (none) to 100 (high) as 65.3 ± 27.7 and 68.1 ± 25.1, respectively. Comparison of smell test results of HHT patients with normative data of sex- and age-matched controls from Hummel et al. revealed that HHT patients had lower threshold values, whereas there was no difference in identification and discrimination values. HHT patients were hyposmic. In the case of taste qualities, all values (sweet, sour, salty, and bitter) in HHT patients were lower than those in normative data of Mueller et al. However, HHT patients were not hypogeusic. The duration of disease, extranasal manifestation, and treatments did not significantly correlate with smell/taste test values.

Conclusion

Compared with healthy people, HHT patients exhibit reduced olfactory and gustatory function; however, HHT patients are hyposmic and not hypogeusic. This chemosensory deficit may highlight an early sign of disease and has no correlation with disease severity. HHT patients should be informed about these potential disease manifestations, thus enabling them to improve their quality of life.

Delayed lymph node metastases after elective neck dissection in patients with oral and oropharyngeal cancer and pN0 neck

PURPOSE

Patients with surgically treated head and neck cancer and clinical N0 neck with high risk of occult lymph node metastasis undergo elective neck dissection (ND). Late lymph node metastasis may appear in those patients with pN0 neck. The aim of the present study was to analyze the incidence and clinical relevance of late lymph node metastasis in patients with head and neck cancer.

MATERIALS AND METHODS

The clinical data of 61 patients with head and neck cancer who had undergone elective ND with pN0 neck were retrospectively analyzed. Only patients without local failure, second primary, or radiochemotherapy were included in the study.

RESULTS

Late lymph node metastasis could be observed in 4 (6.5%) cases at the margin or outside the initially dissected lymph node levels. In those patients, the primary tumor was localized in the oral cavity (n = 3) or oropharynx (n = 1) and was classified in all cases as T1 or T2. Lymph node metastasis could be found in levels I (n = 2), II (n = 1), and IV (n = 1), respectively.

CONCLUSION

Even in the case of pN0 neck after an elective ND, the appearance of late lymph node metastases must be expected. The low proportion of patients with late lymph node metastases after a selective ND in clinical and histologic N0 does not justify an extended form of neck surgery.

EXIT (Ex utero Intrapartum Treatment) in lymphatic malformations of the head and neck: discussion of three cases and proposal of an EXIT-TTP (Team Time Procedure) list

OBJECTIVES

Ex utero Intrapartum Treatment (EXIT) is a technique to secure the fetal airway while oxygenation is maintained through utero-placental circulation. The aim of the study is to present three cases of fetal lymphatic malformation of the head and neck that required EXIT and to summarize EXIT details.

METHODS

The cases were studied before the delivery and EXIT was planned with a multidisciplinary team. The key factors of EXIT are considered and the type, stage and clinical score of the three lymphatic malformations are defined.

RESULTS

In the three cases of EXIT the time working on placental support to secure the airway was 9, 7, and 9 min, respectively (from the hysterotomy to clamping the umbilical cord). Procedures performed on the airway were laryngo-tracheo-bronchoscopy in the first case, laryngoscopy and intubation in the second one, laryngoscopy, drainage of the lymphatic macro-cyst, and intubation in the third case. A sketching to detail the EXIT steps are presented: EXIT-Team Time Procedure list (EXIT-TTP list). Lymphatic malformations were classified as mixed (micro/macro-cystic) in two cases, and macro-cystic in one. de Serres Stage was IV, V and II. Therapy varied in the three neonates (surgery alone, surgery+Picibanil+Nd-YAG, or Picibanil alone).

CONCLUSIONS

In case of prenatal suspicion of airway obstruction, EXIT should be planned with a multidisciplinary team. The EXIT-Team Time Procedure list (EXIT-TTP list), reviews the most critical phases of the procedure when different teams are working together. The type of lymphatic malformation, the anatomic location and the clinical score predict the outcome.

Lack of significant estrogen and progesterone receptor expression in nasal telangiectasias in hereditary hemorrhagic telangiectasia: an immunohistochemical analysis

CONCLUSION

This immunohistochemical study of estrogen and progesterone receptors could not confirm a significant expression in nasal telangiectasias. Thus, a specific effect of these hormones or anti-hormone therapy on malformed nasal vessels has to be questioned and only offered under strict clinical control.

OBJECTIVE

The efforts to control recurrent epistaxis in hereditary hemorrhagic telangiectasia (HHT) using alternative methods are very intense. Hormone or anti-hormone therapy has frequently been postulated and the reported results are controversial. Therefore it was important to find an explanation regarding a possible impact of hormonal therapies by immunohistochemical evaluation of progesterone and estrogen receptor expression on nasal telangiectasias of affected patients.

METHODS

Tissue samples of nasal mucosa with evidence of telangiectasias from 14 patients with HHT were analyzed for the expression of progesterone and estrogen receptors on the nuclei of endothelial cells of the malformed vessels using immunohistochemistry.

RESULTS

Progesterone receptors were not detected in any of the cases and only two cases showed a weak expression of estrogen receptors with an immunoreactive score of 2/12.

Lymphatic malformations involving the parotid gland

INTRODUCTION

Cases of salivary gland involvement of lymphatic malformations have been occasionally reported in the literature. Of all the lymphatic malformations in the salivary glands, the parotid is the most common site. The present study aimed to analyze a series of lymphatic malformations of the parotid gland.

MATERIALS AND METHODS

A retrospective analysis of the localization, symptoms, management and outcome was performed.

RESULTS

Out of a total of 20 patients with lymphatic malformations of the parotid gland, 4 patients suffered from lymphatic malformations limited to the parotid gland (type I) and 16 patients from extensive cervicofacial lymphatic malformations involving the parotid gland (typeII). In 2 cases with type I disease and 4 cases with type II disease the malformations could be completely resected. In 3 patients with type II lymphatic malformations a partial resection was performed. The other patients were closely observed. 8 of them had already been treated elsewhere with surgery, sclerotherapy or laser therapy. One patient suffered from facial paralysis and 1 from transient facial nerve weakness immediately after surgery. In all, 11 patients suffered from persistent lymphatic malformations despite several attempts to reduce or resect the lymphatic malformation.

CONCLUSION

The treatment of lymphatic malformations of the parotid gland remains challenging and persistent disease after therapy is common. Care should be taken to excise the entire malformation during initial surgery in order to avoid recurrence.

Experiences with a new surgical technique for closure of large perforations of the nasal septum in 55 patients

BACKGROUND

The surgical closure of nasal septal perforation is still an unsolved clinical problem. In this study the experiences with a novel surgical technique for closure of large perforations of the nasal septum are presented.

METHODS

A total of 55 patients with symptomatic nasal septal perforation measuring 23 ± 3 mm (range, 11-38 mm) at the widest point were enrolled in the study. The closure of the nasal septal perforation was performed with a new and simple surgical technique using a nasal mucosal flap consisting of the defect-corresponding mucosa of the floor of the nose, inferior nasal meatus, and inferior turbinate.

RESULTS

A symptomatic improvement of nasal symptoms was noted in all treated patients. In only 3 of 55 cases was the perforation closing incomplete.

CONCLUSION

Our experience with this flap shows its reliability and safety in repairing large nasal septal perforations, with many advantages compared with other techniques for septal perforation repair.

Scintigraphic assessment of salivary gland function in a rat model

BACKGROUND

Salivary gland dysfunction with xerostomia is a major clinical problem without a causal therapy in most cases. The development of an animal model for scintigraphic assessment of salivary gland function has great clinical relevance for the investigation of promising new diagnostic and therapeutic strategies for chronic salivary gland diseases. This study reports the first experiences with scintigraphic analyses of salivary gland function in a rat model.

MATERIALS AND METHODS

Anatomical and scintigraphic studies were performed for topographic differentiation of major salivary glands of Wistar rats. (⁹⁹m)technetium pertechnetate salivary gland scanning was performed, appropriate regions of interest were determined and the gland-to-background ratio was examined for the evaluation of salivary gland function.

RESULTS

The quantitative analysis of salivary gland scintigraphy revealed a reliable comparison of major salivary glands on both sides with the gland-to-background ratio ranging from 1.26 to 1.94 with an average of 1.51.

CONCLUSION

This model seems to be appropriate for functional studies in an experimental setting.

Orbital and periorbital vascular anomalies--an approach to diagnosis and therapeutic concepts

CONCLUSION

A correct and universally accepted terminology based on the biologic behavior of orbital vascular anomalies is essential to avoid misleading diagnoses, to choose an adequate therapy regimen, and to compare different therapeutic approaches. The management of these diseases is multi-modal and an interdisciplinary challenge.

BACKGROUND

There is persisting terminological and clinical confusion about vascular anomalies involving the orbit. Review of the literature reveals a diverse or misleading terminology and a lack of consensus for the treatment of vascular malformations or vascular tumors of the orbit.

METHODS

This study comprised a detailed analysis of cases presenting with orbital vascular anomalies followed by an extensive review of the literature.

RESULTS

Thirty-six patients were analyzed, among them 19 patients with peri- and/or intraorbital hemangiomas, 3 with intraorbital and 2 with periorbital venous malformations, 2 with orbital involvement of complex vascular malformations, and 10 with lymphatic malformations involving the orbit.

Analysis of clinically suspected orbital cavernomas

BACKGROUND

Orbital cavernomas are low-flow vascular malformations that are the most common benign neoplasms of the orbit in adults, typically becoming symptomatic in the middle age.

METHODS

The medical records of six patients with clinically suspected orbital cavernomas receiving elective surgical excision were analysed concerning symptoms, physical findings, treatment results and visual outcome. The pathologic slides were evaluated, and additional immunohistochemical stains were done if necessary to obtain diagnosis.

RESULTS

Histologic evaluation revealed three of six cases not being cavernomas, although the clinical and macroscopic findings were consistent with orbital cavernomas. Two of them were haemorrhagic lymphangiomas, and one was a solitary fibrous tumour.

CONCLUSIONS

Haemorrhagic lymphangiomas and other vascular tumours may mimic orbital cavernomas regarding anamnesis, radiologic and intraoperative findings and gross examination. Therefore, exact histologic evaluation is necessary to get the correct diagnosis.

Propranolol therapy for infantile haemangiomas: review of the literature

OBJECTIVES

Haemangiomas are the most common tumors of infancy affecting approximately 1 in 10 children. Unlike other tumors, haemangiomas enter an involution phase, during which they usually regress over the next several months to years. Sometimes intervention is required due to proliferative growth which is complicated by ulceration, bleeding, persistent aesthetic deformity or infection.

METHODS

Review of the literature.

RESULTS

Propranolol, a nonselective beta-blocker, has recently been introduced as a novel modality for the treatment of proliferating haemangiomas. The exact mechanism of action of propranolol in the treatment of haemangiomas remains unclear, but vasoconstriction, down-regulation of angiogenic factors such as VEGF and bFGF and up-regulation of apoptosis of capillary endothelial cells may be responsible for the reduction of haemangiomas. Besides, an inhibition of MMP-9 and HBMEC expression by propanolol is discussed as possible mechanism influencing the growth of haemangiomas. However, there are different case reports of successfully treated infants in the current literature.

CONCLUSION

There is the obtain that propranolol will detach steroids in the therapy for infantile haemangiomas.

Laser treatment of mucosal venous malformations of the upper aerodigestive tract in 50 patients

We examined the clinical appearance of mucosal venous malformations of the upper aerodigestive tract with regard to their accessibility to laser therapy and further assessed the value of treatment of these lesions with the Nd:YAG and CO(2) lasers. A retrospective study was performed in 50 patients who had undergone laser treatment for mucosal low-flow vascular malformations of the upper aerodigestive tract. Records were reviewed for demographic data, extent of the lesion, treatment modality, required number of therapy sessions and the therapeutic outcome. Follow-up was performed by postinterventional clinical examination and additional interview by phone for current status. Between 1 July 2001 and 30 September 2008 32 women and 18 men received laser treatment and were followed up until 30 June 2009. The lesions were classified into three grades according to their extent and clinical presentation, as follows: grade 1 <2 cm, asymptomatic or mild symptoms; grade 2 2-4 cm, asymptomatic or mild symptoms; and grade 3 > or =4 cm or multiple locations (more than two) or severe symptoms such as dyspnoea, pain or dysphagia. Of the 50 patients, 13 (26%) were classified as having grade 1 disease, 22 (44%) grade 2 disease, and 15 (30%) grade 3 disease. Treatment in 39 patients was solely with the Nd:YAG laser using the noncontact or interstitial technique. Resection using the CO(2) laser was performed in six patients, and combined conventional surgery and Nd:YAG laser therapy in five patients. The applied grading reflects the extent of laser therapy and also the number of therapy sessions performed in patients treated with the Nd:YAG laser. Resection with the CO(2) laser is suitable for grade 1 lesions. In advanced lesions a combined therapeutic approach and multiple sessions are necessary. The Nd:YAG laser is still a valuable therapeutic tool for the treatment of venous malformations of the mucosa.

Wyburn-Mason syndrome: a case report

OBJECTIVE

Wyburn-Mason syndrome is a rare disease associated with multiple arteriovenous malformations of the brain, orbit, and face resulting from an insult occurring during embryonic development.

CASE REPORT

We present the clinical and radiological features of a 47-year-old-man with Wyburn-Mason syndrome who suffered from recurrent bleeding episodes primarily at the nasal corner of the left orbit. After radiotherapy and several angioembolisations, surgical reduction with exenteration of the left orbit was performed and resulted in reduced bleeding. Two years later the patient presented with maxillary sinus empyema. Due to massive endonasal bleeding, endoscopy could not be performed and the maxillary empyema was treated via a transorbital approach.

CONCLUSION

Although close observation represents the standard of care in Wyburn-Mason syndrome, patient-specific management decisions are required in the presence of symptoms or complications. In the presented case, surgical intervention proved to be successful.

Orbital lymphatic malformation showing the symptoms of orbital complications of acute rhinosinusitis in children: a report of 2 cases

Orbital lymphatic malformations are benign cystic malformations of the lymphatic system. The present report shows two cases with symptoms of orbital complications of acute rhinosinusitis with proptosis, compressive optic neuropathy, loss of vision and cellulites in children. Magnetic resonance imaging (MRI) revealed a well-demarcated intraorbital mass with heterogeneous signal conformable with lymphatic malformation in both cases. A tumor extirpation was performed via lateral orbitotomy in both cases. Postoperatively the symptoms and especially the loss of vision improved completely. Histological analysis of the surgical specimens verified lymphatic malformations of the orbit. Orbital lymphatic malformations can mimic the symptoms of orbital complications of acute rhinosinusitis. The existence of lymphatic malformation should be considered in every orbital complication of rhinosinusitis in children.

Evaluation of children with lymphatic malformations of the head and neck using the Cologne Disease Score

OBJECTIVES

To assess the disease-related impairments of children with lymphatic malformations of the head and neck and their changes after therapy using the Cologne Disease Score (CDS).

METHODS

29 children with lymphatic malformations of the head and neck were evaluated regarding their symptoms before and after therapy using the CDS. The Wilcoxon test for dependent groups was used to compare the CDS at initial visit before treatment and last visit after treatment.

RESULTS

The CDS of patients belonging to the moderate (initial CDS: more than eight points) and advanced disease group (initial CDS: five, six or seven points) significantly increased after therapy while the patients in the severe disease group (initial CDS: lower than four points) showed no significant improvement of CDS. Patients with stage IV and especially stage V lymphatic malformations according to de Serres showed considerably lower pre- and posttherapeutic CDS levels than those of stage I and II.

CONCLUSIONS

The visual impairment is not mapped by the CDS, therefore item vision should be added to the CDS to make an evaluation of all lymphatic malformations of the head and neck possible. The present series could show that especially patients with a moderate or advanced disease according to the CDS may profit from therapeutic interventions.

Surgery in patients with vascular malformations of the head and neck: value of coagulation disorders

Objectives

The surgical treatment of congenital vascular malformations always bears the risk of severe bleeding. The aim of this study was to investigate the prevalence of haemostatic abnormalities in patients with congenital vascular malformations of the head and neck which could additionally complicate the complex surgery of vascular malformations.

Methods

Thirteen patients with congenital vascular malformations of the head and neck, who underwent scheduled surgery, were reviewed regarding their haemostatic tests, including prothrombin time, activated partial thromboplastin time, fibrinogen level, platelet count, platelet function analyzer-epinephrine (PFA-Epi) and -adenosine diphosphate (ADP) (PFA-100®), von Willebrand factor (vWF) and D-dimers.

Results

In six of 13 patients an impaired primary haemostasis was detected by prolonged PFA-Epi and one of these patients also had a slightly prolonged PFA-ADP. Additionally, two of the patients showed mild coagulation factor deficiency. One patient had a mild vWF deficiency that was not detected by PFA-100®.

Conclusion

Prior to surgery of congenital vascular malformations of the head and neck, a detailed coagulation analysis is needed in order to identify those patients at increased risk of bleeding. This proceeding is supported by the fact that a relevant portion of the patients with congenital vascular malformations of the head and neck show an impaired primary haemostasis.

Update on hemangiomas and vascular malformations of the head and neck

Although the current classification systems of vascular malformations and hemangiomas are increasingly accepted, there are nonetheless several aspects that show us how special and at the same time difficult it is to diagnose, evaluate, and treat some of those diseases. Close interdisciplinary cooperation of all involved disciplines is essential; the discussion of the adequate individual procedure must be performed in angioma boards, as it is already well established in the context of tumor boards. The interface of angioma therapy and tumor therapy seems to be very close, which is certainly true for the aspect of angiogenesis and of course for the inhibited proliferation as promising therapeutic approach of complex vascular malformations. This leads to another obvious necessity of intensifying experimental scientific research on vascular malformations and hemangiomas, which is a precondition for optimizing or elimination of different current problems and deficits in the mentioned field.

Analysis of cytokine levels in human lymphangiomas

BACKGROUND

Different theories concerning the origin of lymphangiomas have been formulated but their precise pathogenesis is still unknown. This study aimed to analyze the levels of different cytokines in lymphangioma cyst fluids.

MATERIALS AND METHODS

Fluid aspirates from lymphangioma cysts of five patients were obtained. The intracystic levels of interleukin (IL)-6, IL-8, IL-2R and tumor necrosis factor alpha (TNFalpha) were determined in four cases before and one case after OK-432 administration using an immunometric assay.

RESULTS

Increased IL-6 levels were observed in all cases. Moreover, elevated IL-2R and TNFalpha levels were observed in three out of four and elevated IL-8 levels in two out of four untreated cases. There was a 25-fold increase in IL-6 after repeated OK-432 injections while IL-8, IL-2R and TNFalpha levels did not change significantly.

CONCLUSION

These findings suggest that cytokines may be involved in the pathogenesis of lymphangiomas.

[State of the art of classification, diagnostics and therapy for cervicofacial hemangiomas and vascular malformations]

The successful treatment of vascular anomalies depends on profound knowledge of the biologic behavior of vascular lesions and their correct classification. On the base of the clinical course Mulliken and Glowacki developed a biologic classification that was accepted as official classification by the ISSVA (International Society for the Study of Vascular Anomalies). Based on an extended literature research, this manuscript will give an overview of different internationally accepted treatment concepts. Even if a wait-and-see strategy can be recommended in many cases of uneventful hemangiomas in infants the proliferative growth of such lesions requires an adequate treatment indication. Vascular malformations that persist lifelong require treatment in the majority of the cases, especially when clinical symptoms occur. Based on individual parameters such as the diameter, location or growth behavior, different therapeutic options as cryotherapy, corticosteroids, laser therapy, sclerotherapy, surgical intervention and/or embolisation can be performed successfully. None of those treatment concepts, however, represents the only treatment method of choice.

Bipolar radiofrequency induced thermotherapeutic volumetric reduction of VX2 metastases in an animal model

BACKGROUND

Radiofrequency-induced thermotherapy has shown promising results in the palliative treatment of various tumor entities. The purpose of this study was to investigate the effectiveness of bipolar radiofrequency volumetric tissue reduction (VTR) on lymph node (LN) metastases in the VX2 SCC model.

MATERIALS AND METHODS

Six male New Zealand white rabbits, with palpable metastatic disease within the parotid lymph nodes, were treated using the Celon-ProSurge probe, needle length 10 mm, diameter of 2.3 mm. The animals were sacrificed on the 4th, 8th, 11th, 14th, 18th and 22nd postoperative days respectively.

RESULTS AND CONCLUSION

Bipolar radiofrequency VTR could prevent progression of local metastatic disease in one-third of the animals compared to the control group of untreated VX2 carcinoma rabbits. These results encourage further studies, directed at whether this treatment modality could play a role in the palliative therapy of metastatic LN. Future studies should concentrate on the refinement of the treatment parameters and optimization of the treatment duration.