American society of pediatric otolaryngology vascular anomalies task force review of tongue venous malformations: Techniques, pearls, and pitfalls

Management of tongue venous malformations can be challenging in the pediatric population due to their heterogeneity in presentation, extent of involvement and functional compromise. It is important to recognize the value of various treatment options in order to guide management of each patient in an individualized fashion. Here we describe a series of patients with tongue venous malformations that are managed using diverse modalities to illustrate the relative benefits and risks of each technique. The challenges of venous malformation treatment can be mitigated by tailoring the approach to each individual patient and malformation. This case series also emphasizes the need and importance of working in the setting of a multidisciplinary vascular anomalies team.

Responsiveness of quality of life measures in children with peripheral vascular malformations: The OVAMA project

Background

The OVAMA (Outcome Measures for VAscular MAlformations) project determined quality of life (QoL) as a core outcome domain for evaluating treatment effect in vascular malformations. To correctly evaluate treatment effect on QoL, patient-reported outcome measures (PROMs) are needed that are responsive to changes. In children with vascular malformations, we explored if two widely used PROMs were responsive to changes: the Pediatric Quality of Life Inventory (PedsQL) and the Children's Dermatology Life Quality Index (CDLQI).

Methods

In an international multicenter prospective study, conservatively and invasively treated children completed the PedsQL and CDLQI at baseline and after follow-up of 6-8 weeks. At follow-up, change in health was assessed by a global rating of change (GRC) scale. Responsiveness was assessed by testing hypotheses on expected correlation strength between change scores of the PROMs and the GRC scale, and by calculating the area under the receiver operating characteristics curve (AUC). The PROMs were considered responsive if ≥75% of the hypotheses were confirmed or if the AUC was ≥0.7.

Results

Twenty-nine children were recruited in three centers in the Netherlands and United States, of which 25 completed all baseline and follow-up measurements. For both the PedsQL and CDLQI, less than 75% of the hypotheses were confirmed and the AUC was <0.7.

Discussion

The results suggest that these PROMs are not sufficiently responsive for evaluating treatment effect in peripheral vascular malformations. Our study emphasizes the need for assessing responsiveness before using a PROM in evaluating treatment effect.

Responsiveness of quality-of-life measures in patients with peripheral vascular malformations: the OVAMA project

Background

The OVAMA (Outcome Measures for Vascular Malformations) project determined quality of life (QoL) as a core outcome domain for patients with vascular malformations. In order to measure how current therapeutic strategies alter QoL in these patients, a patient‐reported outcome measurement (PROM) responsive to changes in QoL is required.

Objectives

To assess the responsiveness of two widely used generic QoL PROMs, the Medical Outcomes Study Short Form 36 (SF‐36) and Skindex‐29, in adult patients with vascular malformations.

Methods

In an international multicentre prospective study, treated and untreated patients completed the SF‐36 and Skindex‐29 at baseline and after a follow‐up period of 6–8 weeks. Global rating of change (GRC) scales assessing various QoL‐related outcome domains were additionally completed. Per subscale, responsiveness was assessed using two methods: by testing hypotheses on expected correlation strength between change scores of the questionnaires and the GRC scales, and by calculating the area under the receiver operating characteristics curve (AUC). The questionnaires were considered responsive if ≥ 75% of the hypotheses were confirmed or if the AUC was ≥ 0·7.

Results

Eighty‐nine participants were recruited in three centres in the Netherlands and the U.S.A., of whom 67 completed all baseline and follow‐up questionnaires. For all subscales of the SF‐36 and Skindex‐29, < 75% of the hypotheses were confirmed and the AUC was < 0·7.

Conclusions

Our findings suggest that the SF‐36 and Skindex‐29 seemed unresponsive to change in QoL. This suggests that alternative PROMs are needed to measure – and ultimately improve – QoL in patients with vascular malformations.

What's already known about this topic?

Quality of life is often impaired in patients with vascular malformations.

Quality of life is considered a core outcome domain for evaluating treatment of vascular malformations.

To measure the effect of treatment on quality of life, a patient‐reported outcome measure is required that is responsive to changes in quality of life.

What does this study add?

This is the first study assessing the responsiveness of quality‐of‐life measures in patients with vascular malformations.

The results seem to indicate that the Medical Outcomes Study Short Form 36 (SF‐36) and Skindex‐29 are not responsive to changes in quality of life in patients with vascular malformations.

What are the clinical implications of this work?

Medical Outcomes Study Short Form 36 (SF‐36) and Skindex‐29 are not ideal to assess the effect on quality of life over time, of treatment strategies for peripheral vascular malformations.

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Medical Management of Acute Facial Paralysis

Acute facial paralysis (FP) describes acute onset of partial or complete weakness of the facial muscles innervated by the facial nerve. Acute FP occurs within a few hours to days. The differential diagnosis is broad; however, the most common cause is viral-associated Bell Palsy. A comprehensive history and physical examination are essential in arriving at a diagnosis. Medical treatment for acute FP depends on the specific diagnosis; however, corticosteroids and antiviral medications are the cornerstone of therapy. Lack of recovery after 4 months should prompt further diagnostic workup.

Outcome Measurement for Vascular Malformations of the Head and Neck

Vascular malformations are congenital anomalies of the vascular and/or lymphatic system that affect the head and neck region. The most common treatment options are sclerotherapy, laser therapy, surgery, and embolization. Because vascular malformations are variable in type, size, extent, and location, it is a challenge to select methods for evaluation of treatment outcome. Without standardized outcome reporting, it is difficult to compare and combine scientific evidence to support therapeutic decision making. Standardized collection and reporting of outcome data are the first steps toward a fair comparison between treatments. This article describes outcome measurements for vascular malformations and initiatives to improve outcome reporting.

The Tissue Expander Effect in Early Surgical Management of Select Focal Infantile Hemangiomas

Importance

The current standard of treatment for infantile hemangiomas (IHs) involves initial observation for regression throughout infancy and childhood, with or without medical management with β-blocker medications. Approximately 50% of the lesions respond almost completely to this regimen. However, the remaining 50% of the lesions, especially established focal IHs of the lip, nose, eyelids, forehead, cheek, and scalp, do not regress completely with this regimen or do so leaving a deformity; among these lesions, early surgical management may result in a superior aesthetic and functional outcome.

Objective

To identify select focal head and neck lesions of IH that will likely not completely involute with medical management and that are ideal for a 1-stage surgical excision.

Design, Setting, and Participants

In this case series, records of infants and children presenting to a tertiary care vascular anomalies center for management of IHs by the senior author were reviewed. Representative examples of focal IHs of the lips, nose, eyelids, cheek, and glabella demonstrating the tissue expansion effect were selected for presentation. Expert opinion based on more than 20 years of experience of the senior surgeon treating more than 2000 patients with focal IH and long-term clinical follow-up is also provided.

Main Outcomes and Measures

Eradication of the IH while restoring aesthetic form and function to the face.

Results

Five examples of patients with focal IHs of the lip, nose, eyelid, cheek, and glabella demonstrating the tissue expander effect who were successfully treated with surgery are presented. The 5 patients with these lesions ranged in age from 3 months to 5 years old, and all of them were female. One of these patients was treated with β-blockers, and another with steroids, with incomplete response to treatment prior to undergoing surgery. The tissue expander effect of a focal IH on adjacent, unaffected tissue facilitated excision of the lesion and primary closure without distortion of anatomical subunits in all 5 of these cases. Improved cosmesis with either improved or unaffected function was demonstrated.

Conclusions and Relevance

Clinicians should consider early surgical intervention in infants with select focal infantile hemangiomas in lieu of prolonged observation or medical management. The psychological benefit of early removal of these disfiguring lesions has not been quantified, but is subjectively apparent to clinicians and the families of patients. Furthermore, the costs and unknown long-term sequelae of β-blocker medication, which is the current standard of treatment for IHs along with observation for regression, have not yet been quantified but will gain increasing salience in the current medical climate.

Level of Evidence

5.

Plasma Epstein-Barr virus immunoglobulin A and DNA for nasopharyngeal carcinoma screening in the United States

Objective

To examine the Epstein-Barr virus (EBV) IgA and DNA assays as a screening tool for nasopharyngeal carcinoma (NPC) in a nonendemic US population.

Study Design and Setting

Prospective study performed at a teaching hospital in New York City. There were two groups of 155 patients: new NPC patients and controls. An otolaryngologic examination and serial blood testing for serologic markers were performed.

Results

Sensitivity and specificity of EBV IgA and DNA assays were determined. Screening scenarios involving series and parallel testing were evaluated to determine economic feasibility. Series testing provided a sensitivity, specificity, and positive and negative predictive values of 90.6, 93.5, 78.4, and 97.5 percent, respectively. Parallel testing increased the sensitivity to 100 percent.

Conclusion

NPC screening in a high-risk, nonendemic population using EBV-specific serologic markers is effective. Series testing is a statistically sound and economically feasible strategy.

Significance

The development of a cost-effective NPC screening strategy in a high-risk, nonendemic population in the United States. © 2007 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

A Biomechanical Evaluation of Auricular Cartilage Autografts in Orbital Floor Defect Repair

OBJECTIVE

Auricular cartilage is used as a surgical implant in the management of orbital floor fractures. However, no specific parameters exist regarding the use/limitations of this potential graft. In order to determine the mechanical efficacy of adult auricular cartilage grafts, a mechanical model was developed and studied for structural threshold size limits.

METHODS

Thirty-seven cadaveric auricular cartilage specimens were tested in a laboratory. A plexiglass baseplate was created with four different sized holes, defined as 1.0×, 1.2×, 1.4×, and 1.6× the mean minor axis of the specimens. Each specimen was used to bridge one hole under increasing loads until mechanical failure. Structural stiffness at three different loading stages, structural failure strength, and percent failure of the entire system for each defect size was calculated.

RESULTS

Specimens tested on 1.0×, 1.2×, 1.4× and 1.6× defects demonstrated 0%, 0%, 20%, and 60% system failure rates, respectively. Structural stiffness curves showed a similar trend, with ANOVA demonstrating a significant difference in mechanical properties between defect sizes (p = 0.03). The curve representing 1.6 × defect size demonstrated significantly reduced structural stiffness relative to 1.0×, 1.2×, and 1.4× curves. There was no statistical difference between 1.2× and 1.4× testing sets (p = 0.09).

CONCLUSION

A clinically significant biomechanical and functional threshold exists between 1.2×and 1.4× defect sizes. Given a mean minor axis of 2.06 cm, orbital blow-out defects <2.4 cm (1.2 × 2.06 cm) are suitable for auricular cartilage grafts; fractures >2.4 cm may require a more rigid material. Cartilage grafts that allow failure, however, may better protect the globe in subsequent injury.

Novel genetic mutations in a sporadic port-wine stain

IMPORTANCE Port-wine stains (PWSs) are common congenital cutaneous capillary malformations. A somatic GNAQ mutation was recently identified in patients with sporadic PWSs and Sturge-Weber syndrome. However, subsequent studies to confirm or extend this observation are lacking.OBSERVATIONS We report a long-standing, unilateral facial PWS of a man in his early 70s confirmed by histopathological analysis. Staged surgical excision of the vascular malformation was performed, and genomic DNA was extracted from the vascular malformation specimen and normal skin. Targeted next-generation sequencing of the coding sequence of 275 known cancer genes including GNAQ was performed in both specimens. A single-nucleotide variant(c.548G>A, p.Arg183Gln) in GNAQ was identified in the PWS-affected tissue but not in the normal skin sample. In addition, this sequencing approach uncovered several additional novel somatic mutations in the genes SMARCA4, EPHA3, MYB, PDGFR-β, and PIK3CA.CONCLUSIONS AND RELEVANCE Our findings confirm the presence of somatic mutations inGNAQ in the affected skin of a patient with congenital PWS, as well as alterations in several other novel genes of possible importance in the pathogenesis of PWS that may also offer substantial therapeutic targets.

Diode laser for the treatment of telangiectasias following hemangioma involution

OBJECTIVE

Infantile hemangiomas are well known for their rapid growth during the first 6 to 9 months of life, followed by a spontaneous but slow involution. The standard of care is to treat these lesions at an early age with propranolol to expedite the involution process; however, surgery still remains an active component in the management. Medical treatment with propranolol or natural involution will often result in residual telangiectasias. We evaluated the efficacy of using a diode laser as a treatment for telangiectasias following cervicofacial infantile hemangioma involution.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care hospital and practice specializing in the care of vascular anomalies.

SUBJECTS AND METHODS

Twenty patients, aged 4 months to 11 years (average 2.69 years), underwent treatment with a 532-nm diode laser to treat the residual telangiectasias following hemangioma involution. All procedures were performed in the operating room. To assess the efficacy, we independently evaluated pre- and posttreatment digital photographs and ranked them on a 0- to 4-point scale (0 = no change and 4 = complete response). Adverse reactions were also recorded.

RESULTS

The telangiectasias showed considerable improvement following treatment. In more than half of the patients treated, the affected area demonstrated a complete response. No adverse reactions were noted.

CONCLUSION

A 532-nm diode laser effectively treats the remaining telangiectasias following hemangioma involution. Whether used independently or in conjunction with other treatment modalities, the diode laser should be part of the surgical armamentarium when treating infantile hemangiomas.

Diode Laser for the Treatment of Telangiectasias following Hemangioma Involution

Objectives:

Infantile hemangiomas are the most common benign tumor of infancy and are well known for their rapid growth during the first 6 to 9 months of life, followed by a spontaneous but slow involution. The standard of care is to treat these lesions at an early age with propranolol to expedite the involution process. Residual telangiectasias often result following involution. We evaluated the efficacy of using a diode laser as an adjunct treatment for cervicofacial infantile hemangiomas.

Methods:

Twenty patients, aged 4 months to 11 years, underwent treatment with a 532-nm diode laser as part of the management for their hemangiomas. The fluence was 10.2 to 25 J/cm2, pulse durations of 36 to 44 ms, spot sizes of 0.7 to 2 mm, and pulse frequency of 3 to 5 Hz. All procedures were performed in the operating room. In order to assess the efficacy, pre- and posttreatment digital photography were evaluated independently by the authors and ranked on a 0 to 4 point scale (0 = no change and 4 = complete response). Adverse reactions were also recorded.

Results:

The telangiectasias showed significant improvement following treatment. In more than half of the patients treated, the affected area demonstrated a complete response. No adverse reactions were noted.

Conclusions:

A 532-nm diode laser effectively treats the remaining telangiectasias following hemangioma involution. The treatment is well tolerated and demonstrates excellent results. Whether used independently or in conjunction with other treatment modalities, the diode laser should be part of the surgical armamentarium when treating infantile hemangiomas.

Lymphatic Malformations of the Airway

Objectives/Hypothesis

To characterize the anatomic distribution of lymphatic malformations of the upper airway.

Study Design

Case series with chart review.

Setting

Tertiary care referral center specializing in the diagnosis and treatment of vascular anomalies.

Methods

A 7-year (2004-2011) retrospective chart review of patients with lymphatic malformations was performed at a tertiary care referral center. Patients with airway lymphatic malformations were identified. The anatomic distribution of lymphatic malformations within the airway was reviewed.

Results

A total of 141 patients with lymphatic malformations of the upper aerodigestive tract (UADT) were studied. Of these, 15 (11%) had laryngeal (supraglottic) involvement. In all of these patients, the disease was above the true vocal folds. Seventy-four (52%) patients had involvement of 1 anatomic zone (most common was the oral cavity), and 67 (48%) had involvement of multiple zones. With regard to each zone, 105 (75%) patients had involvement of the oral cavity, 50 (36%) the oropharynx, 8 (6%) the hypopharynx, 42 (30%) the parapharynx, and 12 (9%) had retropharygeal disease (some patients had multiple zones involved). No patients were identified with glottic, subglottic, or tracheal involvement.

Conclusions

Based on our large series, airway involvement in head and neck lymphatic malformations may occur at multiple sites above the glottis. A high percentage of these patients have involvement of the oral cavity (75%) and oropharynx (35%). None involve the glottis, subglottis, or trachea.

Isolation, characterization, and in vitro propagation of infantile hemangioma stem cells and an in vivo mouse model

Background

Infantile hemangiomas (IH) are the most common benign tumors of infancy. The typical clinical course consists of rapid growth during the first year of life, followed by natural and gradual involution over a multi-year time span through unknown cellular mechanisms. Some tumors respond to medical treatment with corticosteroids or beta-blockers, however, when this therapy fails or is incomplete, surgical extirpation may be necessary. Noninvasive therapies to debulk or eliminate these tumors would be an important advance. The development of an in vitro cell culture system and an animal model would allow new insights into the biological processes involved in the development and pathogenesis of IH.

Results

We observed that proliferative stage IH specimens contain significantly more SALL4+ and CD133+ cells than involuting tumors, suggesting a possible stem cell origin. A tumor sphere formation assay was adapted to culture IH cells in vitro. Cells in IH tumor spheres express GLUT1, indicative of an IH cell of origin, elevated levels of VEGF, and various stem/progenitor cell markers such as SALL4, KDR, Oct4, Nanog and CD133. These cells were able to self-renew and differentiate to endothelial lineages, both hallmarks of tumor stem cells. Treatment with Rapamycin, a potent mTOR/VEGF inhibitor, dramatically suppressed IH cell growth in vitro. Subcutaneous injection of cells from IH tumor spheres into immunodeficient NOD-SCID mice produced GLUT1 and CD31 positive tumors with the same cellular proliferation, differentiation and involution patterns as human hemangiomas.

Conclusions

The ability to propagate large numbers of IH stem cells in vitro and the generation of an in vivo mouse model provides novel avenues for testing IH therapeutic agents in the future.

Otogenic cerebral abscess: an unusual complication of otitis media

Intracranial complications of otitis media are rare in the age of antiobiotics and in the developed world, but they can be life threatening when they occur. We present a case of a 47-year-old woman with no contributory otologic history who developed an otogenic temporal lobe abscess.

Current treatment of parotid hemangiomas

OBJECTIVES/HYPOTHESIS

Parotid hemangiomas are the most common salivary gland tumors in children. Their treatment has posed a challenge because of the lesions' expansive growth, resistance to treatment, and relationship with the facial nerve. Various treatment modalities have been attempted, and promising results have been achieved with surgical resection alone or in conjunction with endovascular sclerotherapy. Recently, bleomycin and oral propranolol have been introduced, and the results thus far are promising. Here we elucidate the treatment options and propose a treatment algorithm for parotid hemangiomas.

STUDY DESIGN

Retrospective chart review.

METHODS

We conducted a retrospective chart review of patients from 2004 to 2009 with hemangiomas involving the parotid gland. We included 56 patients and relevant parameters.

RESULTS

Seventy percent of patients were female. The female-to-male ratio was 2.3 to 1. Thirty-nine percent had unilateral parotid hemangiomas, 12.5% had cutaneous segmental hemangiomas. All 22 patients who underwent systemic steroid therapy responded initially, but 68% of these rebounded after cessation of therapy. Sixteen patients (29%) underwent surgery with excellent results (facial symmetry, restoration of contour, preserved facial nerve function). Seven (44%) patients received sclerotherapy 24 to 48 hours before surgery, and five (8%) received endovascular sclerotherapy alone. Ten patients were treated medically with oral propranolol. Eight of 10 had significant shrinkage of the lesion within the first month of treatment. There were no reported side effects.

CONCLUSIONS

Multiple treatment regimens have been used to successfully treat parotid hemangiomas. Although propranolol is a recent addition, it seems most promising. Further evaluation is warranted.