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Case study

Treatment of haemangioma of E.N.T and Head & Neck region with Inj. Polidocanol
Rohit Saxena1, Ajay Lavania2, Sunil Singh Bhadouriya3, Sushil Gaur4,
Samvartika Somavanshi5 - Noida ( U.P.)
A hemangioma is a benign, and usually a self-involuting tumor, (swelling or growth) of the endothelial cells that line the blood
vessels and is characterised by an increased number of normal or abnormal vessels filled with blood. In infancy, it is the most
common tumor. The possible sites of occurrence in the oral cavity are lips, tongue, buccal mucosa, and palate. Despite its benign
origin and behavior, it is always of clinical importance to the E.N.T and Head and Neck Surgery and thus requires appropriate
management. This case study reports 15 cases of haemangioma presented in various parts of E.N.T & Head and Neck Surgery
during the year 2010-2012, and they were managed conservatively using sclerosing agent Inj. Polidocanol in 30 Mg. strength
diluted with distilled water in 1: 3 concentration. 14 out of 15 patients had considerable relief of the symptoms, cosmetic
improvement with minimal complications.
Key word : Haemangioma E.N.T and Head and Neck, Sclerosing agent- Polidocanol

Introduction systemic treatment. Other treatments that have been used

The terminology used to define, describe and categorize include interferon or vincristine. They may be considered if
vascular anomalies as abnormal lumps made up of blood first-line therapy fails.Besides these, the other modalities used
vessels, has changed. The term haemangioma was originally in the management of oral haemangiomas include:
used to describe any vascular tumor -like structure, whether it cryotherapy4 embolization5 photocoagulation6and carbon
was present at or around birth or appeared later in life. dioxide laser 7 Surgical removal is sometimes indicated,
The cause of haemangioma is currently unknown; however, particularly if there has been delay in commencing treatment
several studies have suggested the importance of estrogen and structural changes have become irreversible.
signaling in haemangioma proliferation. In 2007, a paper Materials and Methods
from the Stanford Children's Surgical Laboratory revealed The present study was conducted in the department of E.N.T
that localized soft tissue hypoxia coupled with increased and head and Neck Surgery, School of Medical Sciences and
circulating estrogen after birth may be the stimulus.1 There is Research, Greater Noida between 2010 to 2012 on 15 cases of
also a hypothesis presented by researchers at Harvard and the Haemangioma of E.N.T and Head and Neck Region. All the
University of Arkansas that maternal placenta embolizes to case were diagnosed clinically and all of the were treated with
the fetal dermis during gestation resulting in haemangioma Inj Polidocanol 30mg diluted in 1:3 concentration with
genesis.2 More research is required in order to fully distilled water. Inj Polidocanol is a potential sclerosant with
understand the explosive nature of haemangioma growth, local anaesthetic property .
which will hopefully yield targeted therapeutics to treat its Inj Polidocanol 30 mg diluted in 1:3 concentration with
most complicated presentations.Most haemangiomas distilled water was injected intralesionally at multiple sites
disappear without treatment, leaving minimal or no visible mainly at the centre and at the periphery with 2 ml syringe. 1 to
marks. Large haemangiomas can leave visible skin changes 2 ml of Inj Polidocanol was injected in one sitting depending
secondary to severe stretching of the skin or damage to on size of the lesion and age of the patient. Manual
surface texture. When haemangiomas interfere with vision, compression was applied at the periphery of the lesion to
breathing, or have the threat of significant cosmetic injury confirm stasis where ever it was possible. The same process
(facial lesions and in particular, nose and lips), they are was repeated after a gap of two weeks. Upto 5 injections were
usually treated.Until recently, the mainstay of treatment was given depending on the size of the lesion.All the patients had
oral corticosteroid therapy, but there are now alternative mild to moderate pain and irritation at the site of injection. For
treatments. A randomized trial showed that the beta-blocker pain they were given oral analgesics for 2 to 3 days.
propranolol reduced severe haemangiomas in infants.3 The Results
topically applied beta blocker solution/gel Timolol is also 14 out of 15 patients had considerable relief of the symptoms,
being tried for small facial haemangiomas that do not justify cosmetic improvement with minimal complications. In 12
Professor and Head, 2Associate Prof,3,4Senior resident,5Resident, Dept. E.N.T and Head & Neck Surgery;
School of Medical Science & Research; Greater Noida; U.P; India

12 National Journal of Otorhinolaryngology and Head & Neck Surgery, Vol. 1(10) No. 1, April 2013
patients the lesion regressed completely while 2 patients had disappear without treatment, leaving minimal or no visible
partial regression with cosmetically accepted condition and marks.
one patient did not respond to treatment and later managed for Up until recently, the mainstay of treatment was oral
close follow up. Two patients had an ulcer, three patients had corticosteriod therapy. Beta blocker treatment using agents
pain, and three patients had localized oedema, at the tongue such as propanolol is revolutionizing therapy, producing
but they recovered completely within two weeks. impressive responses. A publication in the international
Hence success rate of the present study was 93% literature in June 2008 first suggested that propranolol (a Beta
blocker) could be used to treat severe haemangioma 9.This
treatment is proving superior to corticosteroids, in terms of
both effectiveness and safety. Surgical removal is sometimes
indicated, particularly if there has been delay in commencing
treatment and structural changes have become irreversible.
Fig-1 (Pre Op) Fig-2 (Post Op)
1. Kleinman ME, Greives MR, Churgin SS, et al. (December
2007). "Hypoxia-induced mediators of stem/progenitor
cell trafficking are increased in children with hemangiom
". Arterioscler. Thromb. Vasc. Biol. 27 (12): 2664–70.
2. Barnés CM, Huang S, Kaipainen A, et al. (December
2005). "Evidence by molecular profiling for a placental
Fig-3(Pre Op) Fig-4 (Post OP) origin of infantile hemangioma". Proc. Natl. Acad. Sci.
Discussion U.S.A.102 (52): 19097–102.
The word "Haemangioma" comes from the greek word – 3. Hogeling M et al. (August 2011). "A randomized
haema means blood, angio means vessel & the suffix oma controlled trial of propranolol for infantile
means tumour, as a result it is a blood vessel tumor.It is a hemangiomas". Pediatrics 128 (2): 259-266
tumor of infancy & most cases appear during the first few 4. 4. Chaplin M E. Cryosurgery of benign oral lesions. J
days or weeks of life & resolve within the age of 10 Dermatol Surg Oncol 1977;3:428-31.
years.Haemangiomas are common lesions of face, nose, 5. Braun I F, Levy S and Hoffman J C (Jr). The use of
throat, ear, neck, liver and most often seen to involve the lips, transarterial microembolization in the management of
tongue and buccal mucosa. They are classified into three basic hamangiomas of perioral region. J Oral Maxillofac Surg
types, capillary haemangioma, cavernous haemangioma and 1985;43:39-48.
arterial or plexiform haemangioma. Before considering the 6. 6. Morreli J G, Tan O T and Weston W L. Treatment of
haemangioma, it is important to understand that there have ulcerated hemangioma with the pulse tunable dye laser.
been changes in the terminology used to define, describe and Am J Dis Child 1991;145:1062-64.
categorise vascular anomalies. The term haemangioma was 7. Apfelberg D B, Maser M R, Lash H and White D N.
originally used to describe any vascular tumor like structure, Benefits of the carbon dioxide laser in oral hemangioma
where it was present at or around birth or appeared in later excision. Plast Reconstr Surg 1985;75:46-50.
life.Haemangiomas are the most common childhood tumor. 8. C.M. Branes, S. Huang, A. Kaipainen, et al. "Evidence by
Females are five times more likely to have haemangiomas molecular profiling for a placental origin of infantile
than males but all our patients are males. They are also Journal of College of Medical Sciences-Nepal, 2012, Vol-
common in twin pregnancies. Approximately 80% are located 8, No-1 59
on the face and neck, with next the most prevalent location 9. hemangioma" Proc Natl Acad Sci U.S.A 2005; 102
being the liver 8 The most frequent complaints about (52):19097 –102.
haemongioma, however, stem from psychosocial
complications, the condition can affect a persons appearance Address for Correspondence
and can provoke attention and malicious reaction from Dr Ajay Lavania
others.The potential for psychological injury develops from Asso. Prof. School of Medical Science & Research,
school age group onwards. It is therefore important to Greater Noida, U.P.
consider treatment prior to school, if adequate spontaneous E mail :
improvement has not occurred. Most haemoagiomas Cell : +91 9911363002

13 National Journal of Otorhinolaryngology and Head & Neck Surgery, Vol. 1(10) No. 1, April 2013