Piotr Kwast, Monika Jabłońska-Jesionowska, *Lidia Zawadzka-Głos
Analysis of treatment in patients with infantile hemangioma in the Department of Pediatric Otolaryngology, Medical University of Warsaw
Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Lidia Zawadzka-Głos, MD, PhD
Summary
Introduction. Infantile hemangiomas in the region of head and neck are relatively common. When localized in the vicinity of vital organs, airways or the eye, they may cause a serious threat to the child’s health and development, or even life. The recently discovered effectiveness of propranolol in treating infantile hemangiomas enabled the development of a fast and safe treatment methods of these lesions in laryngological patients.
Aim. The purpose of this study was to analyze the patients with infantile hemangioma and their treatment with a view to the latest findings and therapeutic standards.
Material and methods. Children hospitalized in the years 2013-2015 in the Department of Pediatric Otolaryngology at the Medical University of Warsaw with the diagnosis of infantile hemangioma of the head and neck were included in the study. Data concerning patients’ age and sex, location of the lesion, any additional lesions and duration of the propranolol therapy, as well as the response to treatment, were collected for the study.
Results. We included 17 patients (12 girls and 5 boys) in the study. Hemangioma was located in the larynx in 8 cases, there were 3 cases of hemangioma of the tongue, 3 cases of hemangioma of the nasal cavity and 3 cases of a hemangioma in a different location: cheek, parotid gland and palate. In 3 cases, there was an additional hemangioma localized outside of the head and neck region. 11 patients were under one year old at the beginning of treatment. Treatment duration varied from 3 to 12 months. In all cases in which propranolol was introduced in infancy, we observed complete remission of the changes.
Conclusions. Propranolol treatment for infantile hemangioma is a very effective and safe way for reducing the mass of the lesion. It allows to reach complete remission when administered early enough.
INTRODUCTION
Nearly every pediatrician has seen a case of infantile hemangioma in their medical career. These lesions, often compared to strawberries because of their red color and uneven surface, can be found in as many as 10% of infants (1). They are benign congenital vascular tumors, and even though in most cases they disappear during the first years of childhood, some of them may pose a threat to the child’s health or even life.
Names under which various vascular lesions were known throughout the years, changed many times as new classification methods were introduced. The first important classification was created in the 19th century and was based on pathological findings. Hemangiomas were divided into plaque-like and cavernous – a distinction which is still in use today. However, this classification did not take into consideration biological differences and dynamics of growth and involution of various types of vascular tumors. In the 1980s, Mulliken and Glowacki distinguished two major groups of congenital vascular lesions: hemangiomas and vascular malformations (2), based on clinical presentation as well as on endothelial characteristics. This classification allowed to predict the natural development of lesions and to choose treatment options appropriately.
The most recent classification comes from 1996 and divides vascular lesions into vascular tumors (including infantile hemangiomas) and vascular malformations (1).
The most important difference between infantile hemangiomas and other seemingly similar lesions is their characteristic behavior in time. Infantile hemangiomas are almost never found at birth. They are noticed during the first weeks of the child’s life and then continue to grow. The rapid onset of the disease and its fast growth usually prompt parents to seek medical attention. Infantile hemangiomas have a tendency to develop during the first year of life, with a following period of gradual involution over the course of the next few years. Vascular malformations, on the other hand, are usually present at birth and grow proportionally with the child with no tendency to shrink or recede with time. This major difference allows the physician to accurately classify the lesion based on medical history and examination (1).
Infantile hemangiomas may present as bright-red lesions located on the very surface of the skin. Such hemangiomas are usually very characteristic and easy to recognize. Tumors located in the deeper tissues often require imaging studies for the accurate diagnosis. The skin over such fast-growing tumor is usually pale or with small telangiectasias, which may lead a less experienced physician towards a different diagnosis. In such cases, ultrasound and sometimes computed tomography provide sufficient information to make the right diagnosis.
Over two thirds of hemangiomas are localized in the head and neck region (1). Lesions in this area may influence both the physical and psychological development of a child. Hemangiomas localized near airways and natural body orifices may impair their patency: even a small hemangioma of the larynx, trachea or nasal cavity may obstruct the airways, leading to respiratory failure. Hemangiomas localized in the vicinity of the eyelid may impair both ocular mobility and proper eyesight. Large hemangiomas may cause problems with circulation and bleeding disorders. In preschool and older children, a lesion of the face that is still visible may lead to rejection and difficulties in bonding with peers.
Hemangiomas localized outside the head and neck region usually appear on the torso and upper extremities. Patients with such tumors are less likely to require medical intervention, as it is safer to wait for the lesion to recede on its own.
Most infantile hemangiomas are solitary, however, about one fifth of them are accompanied by other hemangiomas in a different location on the skin or in deeper tissues. A particular group of patients are children with multiple hemangiomas on the lower part of the face and the neck. Such hemangiomas are often an element of the PHACES syndrome, in which they are associated with central nervous system anomalies, cardiac defects, eye anomalies and sternal raphe.
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Piśmiennictwo
1. Wyrzykowski D, Bukowski M, Jaśkiewicz: Guzy naczyniowe i wrodzone malformacje naczyniowe. J Cancer Surgery 2009; 1: 1-17. 2. Mulliken JB, Glowacki J: Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg 1982 Mar; 69(3): 412-422. 3. Bota M, Popa G, Blag C, Tataru A: Infantile Hemangioma: A Brief Review. Clujul Med 2015; 88(1): 23-27. 4. Denoyelle F, Leboulanger N, Enjolras O et al.: Role of Propranolol in the therapeutic strategy of infantile laryngotracheal hemangioma. Int J Pediatr Otorhinolaryngol 2009 Aug; 73(8): 1168-1172. 5. Vivas-Colmenares GV, Fernandez-Pineda I, Lopez-Gutierrez JC et al.: Analysis of the therapeutic evolution in the management of airway infantile hemangioma. World J Clin Pediatr 2016 Feb 8; 5(1): 95-101. 6. Lèautè-Labrèze C, Dumas de la Roque E, Hubiche T et al.: Propranolol for severe hemangiomas of infancy. N Engl J Med 2008 Jun 12; 358(24): 2649-2651. 7. Hardison S, Wan W, Dodson KM: The use of propranolol in the treatment of subglottic hemangiomas: a literature review and meta-analysis. Int J Pediatr Otorhinolaryngol 2016 Nov; 90: 175-180. 8. Bajaj Y, Kapoor K, Ifeacho S et al.: Great Ormond Street Hospital treatment guidelines for use of propranolol in infantile isolated subglottic haemangioma. J Laryngol Otol 2013 Mar; 127(3): 295-298. 9. Lèautè-Labrèze C, Hoeger P, Mazereeuw-Hautier J et al.: A randomized, controlled trial of oral propranolol in infantile hemangioma. N Engl J Med 2015 Feb 19; 372(8): 735-746. 10. Liu X, Qu X, Zheng J, Zhang L: Effectiveness and Safety of Oral Propranolol versus Other Treatments for Infantile Hemangiomas: A Meta-Analysis. PLoS One 2015 Sep 16; 10(9): e0138100.
