Open excision of subglottic hemangiomas to avoid tracheostomy

OBJECTIVE: To assess the efficacy of open excision as an alternative to tracheostomy in the management of subglottic hemangioma. DESIGN: A retrospective review of patients undergoing open surgical excision of subglottic hemangiomas over a 10-year period. SETTING: A tertiary pediatric center. PATIENTS: The study included 22 children ranging in age from 2 to 42 months (median age, 5 months) who underwent open excision of subglottic hemangioma over a 10-year period. RESULTS: Twenty-one patients were treated with single-stage procedures, with postoperative endotracheal intubation for an average of 5 days. One patient who had a preexisting tracheostomy was treated with a 2-stage procedure and underwent decannulation 2 months after excision. Seven other patients were tracheostomy dependent at the time of excision and underwent decannulation at the time of the procedure. Cartilage grafts were inserted in 10 patients. There were no problems with subglottic stenosis. Twenty-one patients reported good voice and no airway symptoms after a mean follow-up period of 42 months. Five patients had significant postoperative problems. Three patients required further endoscopic procedures for removal of granulation tissue, and 1 patient, who remains minimally symptomatic, developed an anterior glottic web. One patient required a 6-month course of steroids after surgery to treat residual glottic hemangioma. CONCLUSIONS: Open surgical excision of subglottic hemangiomas can be performed as a single procedure, avoiding a tracheostomy, when modern surgical techniques developed for laryngotracheal reconstruction are incorporated. This approach can avoid repeated endoscopic procedures, prolonged treatment with corticosteroids, and years spent with a tracheostomy waiting for spontaneous involution of the hemangioma.     

Treatment of nasal hemangiomas

Hemangiomas are the most common soft tissue tumors of infancy. Almost 60% of these tumors develop in the head and neck region. Nasal hemangiomas, distort human physiognomy and leave long lasting psychological sequelae. Conservative approach (intralesional corticosteroids, laser) may accelerate involution. Proponents of an early surgery suggest that aesthetic improvement during a critical period in child development can be achieved. Fourteen patients with nasal hemangioma were treated during 5-year period (2003-2007) with intralesional corticosteroids, lenticular excision, open rhinoplasty excision, and circular excision with “purse string suture”. The first line of treatment for large nasal hemangiomas is intralesional corticosteroids. Excision is indicated for small hemangiomas, while subtotal excision is preferable for large nasal hemangiomas. Circular excision and “purse string suture” is appropriate for prominent hemangiomas with predominant deep component. In our opinion surgery with maximal care for nasal architecture is the treatment option for nasal hemangioma.     

A comparison of gastrostomy techniques in patients with advanced head and neck cancer.

Patients with advanced head and neck carcinomas often suffer from impaired deglutition and require prolonged enteral feedings during therapy. This retrospective study analyzed 75 patients managed with three different gastrostomy techniques. Thirty patients received a percutaneous endoscopic gastrostomy; 28 patients had an open tube gastrostomy using a Foley or Malecot catheter through a purse-string stay suture; and 17 patients received an open-tube gastrostomy with a 1-cm Dacron-cuffed Silastic catheter enclosed in a 3-cm Witzel tunnel with the cuff buried in the subperitoneal pocket. The complication rate for 100 days of tube use was 0.21 for cuffed Silastic gastrostomy, 0.35 for open tube gastrostomy, and 1.41 for the percutaneous endoscopic gastrostomy group. We conclude that the cuffed Silastic gastrostomy technique is superior in this patient population.     

Keloid banding using suture ligature: a novel technique and review of literature

Introduction: Successful wound healing represents the coordinated response of cellular, cytokine, and growth factor mechanisms involved in tissue recovery. Disruptions in transforming growth factor‐β signaling, senescence/apoptosis, keratinocyte‐fibroblast interactions, and other regulatory cascades can lead to the production of hypertrophic scar or keloid tissue formation. Current clinical investigations support surgical excision, meticulous closure, postoperative steroid injections, and postprocedural pressure dressings in the treatment of keloid tissue formation. Unfortunately, a universal approach in keloid therapy has yet to be identified. Here we offer a novel banding technique using suture ligature for the removal of these tissues. Methods: Using a suture ligature, keloid tissues were banded along their base for a 5‐week period. Tissue evaluation and additional suture banding was performed on a weekly basis until complete mummification and spontaneous removal of ligated tissues. No additional pressure dressings were placed after tissue removal as treated sites had essentially undergone pressure therapy from the banding treatment. Results: Keloid tissues from multiple sites of the head and neck were effectively removed without complication using the suture banding technique. During a follow‐up period of 12 months, no evidence of keloid tissue recurrence was observed. Conclusion: Keloid tissue formation remains a formidable challenge for the patient and physician alike. The application of a simple tissue banding technique holds promise in the direct and preventative treatment of keloid tissue formation whereas the end results merit further clinical and laboratory investigation.     

Advances in facial rejuvenation surgery

There have been many important contributions to the literature on the subject of facial rejuvenation surgery. There has been a trend toward less invasive techniques that offer patients shorter recovery periods with levels of aesthetic satisfaction comparable to those of more invasive and complex procedures. Techniques reviewed in this article include midface suture meloplication, and purse-string suture suspension of the superficial musculoaponeurotic system to effect changes in the lower one third of the face. Another exciting area is the use of fibrin sealants and autologous platelet gels to enhance the adhesion of the tissue flaps at closure and reduce the amount of ecchymosis and edema in the recovery period. Their ability to decrease bruising, swelling, and lessen the frequency of complications has the potential of increasing patient satisfaction through a quicker return to normal activities.     

Controlled risk of stenosis after surgical excision of laryngeal hemangioma

OBJECTIVE: To evaluate the risk of subglottic stenosis after surgical excision of congenital subglottic hemangioma. DESIGN: Retrospective analysis and case series. SETTING: Tertiary care teaching hospital. PATIENTS: A total of 13 pediatric patients diagnosed with subglottic hemangioma with unilateral, bilateral, or circular lesions and more than 50% airway obstruction between 1992 and 2001. INTERVENTION: Open surgical excision was performed as a single-stage procedure either as primary or secondary intention. The cricoid cartilage was left open at the end of the procedure. Postoperative intubation was carried out in a pediatric intensive care unit. MAIN OUTCOME MEASURE: An adequate airway after surgical excision. RESULTS: All patients were successfully extubated. No recurrence was noted. Three patients developed subglottic stenosis, two grade 1 and one grade 2. All 3 showed a favorable outcome and did not require reintubation. One needed endoscopic management of the stenosis. Of these 3 cases, 2 occurred after carbon dioxide laser treatment (out of 3) and 1 after circumferential dissection (out of 3). CONCLUSIONS: Extubation after surgery was successful in all cases of subglottic hemangioma. Risk of subglottic stenosis was limited and occurred only after circumferential dissection, especially if associated with prior traumatic laser damage of the hemangioma.     

Glottic airway gain after ‘suture arytenoid laterofixation’ in bilateral vocal cord paralysis

Conclusion: This method is an easy, non-expensive, and effective technique in bilateral vocal cord paralysis to improve glottic airway and clinical performance. Objective: To evaluate the effectiveness of ‘suture arytenoid laterofixation’ surgery in bilateral vocal cord paralysis. Materials and methods: A retrospective analysis of patients’ medical history undergoing ‘suture arytenoid laterofixation’ surgery for bilateral vocal cord paralysis. This technique was applied under general anesthesia with both microlaryngoscopy and video-monitoring. Two 16 g needles and one 1/0 nylon thread were used for the procedure with 1 cm skin incision; no tracheotomy or tissue excision was required. Pre–post-operative photographs of the glottic region were taken from the endoscopic records, and the areas of rima glottis openings were calculated with the Image-J programme. Results: Forty-seven patients were analyzed. The mean pre–post-operative rima glottis areas were 1.11 ± 0.56 and 2.24 ± 0.93 mm², respectively (p < 0.001). Five patients with previous tracheotomy were decannulated within a few days after the operation. In three patients, mild complications developed in the early post-operative period (two laryngeal edemas, one submucosal hematoma). Tracheotomy was performed to only one pregnant patient in the post-operative first day. None of the patients had granulation formation or synechia.     

"Bleeding polyp" of the nasal septum: an uncommon lesion in adults

Inflammatory hemangioma of the nasal septum, known as "bleeding polyp," is an uncommon lesion in adults. We report the case of a 20-year-old woman who presented with left nasal hemangioma revealed by unilateral epistaxis and obstruction. The patient had a medical history of septoplasty performed 5 years earlier. This benign tumor can be spontaneous or posttraumatic and occurs in young postpubertal adults or patients over 40 years of age, without a sex preponderance. The site of origin is most frequently the cartilaginous septum. The appearance and clinical signs often mimic malignancy, and a biopsy for histologic confirmation of the diagnosis is crucial. The capillary hemangioma is more frequently observed than the cavernous type. This tumor does not present spontaneous involution, and treatment is based on a surgical excision including the mucosa and the underlying perichondrium, after computed tomographic and/or nuclear magnetic resonance examination.     

Management of laryngeal hemangioma in adults: a case report

Hemangiomas are the most common vascular tumors mostly (60%) seen in the head-neck region. Head-neck hemangiomas are seen frequently in the oral cavity, rarely in the larynx. Adult laryngeal hemangiomas are rare and often seen in the supraglottic region, therefore causing dysphagia/dysphonia. We presented two-cases with laryngeal hemangioma, discussed the diagnosis, treatment and follow-up of adult cavernous hemangiomas. A forty-one-year-old female patient applied to hospital with hoarseness and breathing difficulty lasting for three years. A cavernous hemangioma located on laryngeal surface of the epiglottis was excised through a transoral endoscopic approach. The patient had no symptoms after the operation but on the postoperative 34th month follow-up she was admitted to our clinic again because of difficulty during swallowing. Relapsed hemangioma was diagnosed and reoperated by open surgery (laryngofissure). After reoperation the patient had symptomatic relief in three months and videolaryngoscopic examination showed granulation tissue. The patient's regular follow-up was continued. A forty-year-old female other patient was applied to hospital with hoarseness and swallowing difficulty worsening in three months. Hemangioma located in the postcricoid area with extensive to hypopharynx-esophagus junction was diagnosed. The location of the lesion in imaging techniques was evaluated with the thoracic surgery and gastroenterology department and we decided not to do any operation and follow-up patient by considering the severity of symptoms, location of lesion and complications of operation.     

Management of middle ear hemangiomas

Hemangioma rarely presents as an isolated middle ear lesion. Because congenital hemangiomas usually regress spontaneously, surgical excision is not always necessary. However, a hemangioma in the middle ear can be complicated by infection and hearing impairment. We present 2 cases to show contrasting management strategies, both with successful outcomes. Two children who presented with unilateral otitis media were found to have concomitant mesotympanic hemangiomas on examination. The first child was asymptomatic and subsequently had an incisional biopsy, confirming the suspected diagnosis. The residual tumor then involuted over the following year. The second child, however, developed chronic otitis media refractory to medical therapy and required surgical removal of the entire hemangioma. Once a tissue diagnosis is made, middle ear hemangiomas can be managed expectantly (ie, wait for spontaneous resolution) or surgically. If growth of a middle ear hemangioma appears to be causing complications refractory to conservative therapy, then early surgical excision may be indicated.     

Cavernous hemangioma of the tympanic membrane and external ear canal

OBJECTIVES: The aims of this study are to document the occurrence of a cavernous hemangioma of the tympanic membrane (TM) and external auditory canal (EAC) that invaded the middle ear spaces and to review the relevant literature. METHODS: The clinical presentation, imaging studies, operative report, and histologic findings of this new case of cavernous hemangioma are reviewed. RESULTS: A cavernous hemangioma of the TM and EAC involving the middle ear spaces was surgically excised without complications. The pulsatile tinnitus, which affected our patient at the same ear where the lesion was situated, disappeared after surgery. Our case represents the first documented cavernous hemangioma of the TM and EAC that invaded the middle ear spaces and the eighth case of cavernous hemangioma of the EAC/TM. Computed tomography is the method of choice in evaluating this lesion. CONCLUSIONS: Hemangiomas of the EAC and/or TM are extremely rare entities amenable to surgical excision. With magnetic resonance imaging, there is difficulty in defining the exact location of the tumor and degree of soft tissue involvement.     

Open excision of subglottic hemangioma with microscopic dissection

OBJECTIVE: To evaluate the efficacy of open excision of subglottic hemangioma utilizing microscopic dissection techniques. DESIGN: Retrospective review of case series. SETTING: Tertiary care teaching children's hospital. PATIENTS: The study included 8 patients ages 7 weeks to 8 months. All patients underwent open microscopic excision of subglottic hemangioma between 2000 and 2006. INTERVENTION: All patients underwent full pre-operative evaluation including micro-direct laryngoscopy and bronchoscopy. All resections were carried out with an anterior cricoid split and partial laryngofissure. Intra-laryngeal dissections were carried out under a cross-table binocular dissecting microscope. Mucosal preservation was practiced whenever possible. Thyroid ala cartilage graft was used to augment subglottic laryngeal framework. Patients were intubated for 3-7 days prior to reassessment and extubation. RESULTS: Eight patients were treated with microscopic open excision of subglottic hemangioma. All patients were successfully extubated. During the follow-up period, 2/8 patients developed early subglottic stenosis that required endoscopic laser treatment. Median follow-up time was 37 months (range 3-84 months). No recurrences have been observed. CONCLUSION: Microscopic dissection adds precision to open excision of subglottic hemangioma. Such precision enables complete excision while accomplishing maximal mucosal preservation, thus limiting the risk of recurrence and subglottic stenosis.     

Infantile supraglottic hemangioma: a case report

Hemangiomas of the airway are benign vascular lesions that can involve any site from the nares to the tracheobronchial tree. Most of these lesions are seen in the subglottic area in infants. Supraglottic infantile hemangiomas are very rare. We report a case of supraglottic hemangioma in a 2-month-old boy who had been admitted to our hospital with inspiratory stridor and dyspnea. The hemangioma involved the left arytenoid and aryepiglottic fold. A tracheostomy was performed, and the patient was followed up endoscopically every 6 months thereafter The hemangioma disappeared when the child was 30 months old. Subsequently, a Montgomery T-tube was placed for 6 months to assist in maintaining normal breathing. The patient remains disease-free during ongoing follow-up. We also discuss the management strategies for infantile laryngeal hemangiomas.     

Use of potassium titanyl phosphate (KTP) laser in management of subglottic hemangiomas

OBJECTIVE: to study the role of KTP laser in management of subglottic hemangioma. DESIGN: retrospective analysis of patients with subglottic hemangioma treated by the senior authors. Setting: tertiary care teaching hospital. PATIENTS: twelve patients with subglottic hemangiomas. INTERVENTION: patients were treated with KTP laser (eight cases), CO(2) laser (two cases) or observation (two cases). MAIN OUTCOME MEASURE: resolution of symptoms, decrease in size of subglottic hemangioma or tracheotomy decannulation. RESULTS: All patients treated with KTP laser or CO(2) laser had resolution of symptoms and five tracheotomy-dependent children were decannulated. CONCLUSION: subglottic hemangioma is a potentially life-threatening disease seen in young children. Most authors recommend use of either CO(2) or open surgical excision. There is very little data available on the use of KTP lasers in the management of subglottic hemangiomas. The KTP laser beam is preferentially absorbed by hemoglobin making this laser system more applicable to the treatment of vascular tumors such as the hemangioma. KTP laser is a good tool for management of subglottic hemangioma with a low incidence of complications.     

Ultrasound‐guided radiofrequency submucosal tongue‐base excision for sleep apnoea: a preliminary report1

Ultrasound‐guided radiofrequency submucosal tongue‐base excision for sleep apnoea: a preliminary report Surgery for sleep apnoea is challenging, particularly in patients with macroglossia. This has led us to develop a new procedure for reduction of the tongue base with low morbidity. Two types of bipolar radiofrequency probe were used via a percutaneous approach under an aseptic technique and general anaesthesia on 15 consecutive patients with retropalatal and retrolingual collapse. The lingual neurovascular bundles and probe were simultaneously identified with intraoperative real‐time ultrasound to prevent neurovascular damage, and five patients had additional tongue mucosal suture advancement. All patients had previous or concurrent palatal surgery. The increase in cephalometric (retrolingual) posterior airspace (PAS) was 4 mm with a Spinevac wand and mucosal suture advancement, which is comparable to current‐staged monopolar radiofrequency protocols requiring treatment for up to 6 months. Overall, 40% polysomnographic success was achieved, but it was 80% when additional phase 1 procedures were used. Morbidity was minimal with careful adherence to the perioperative care protocol.     

Evolving treatments in the management of laryngotracheal hemangiomas: will propranolol supplant steroids and surgery?

There has been a dramatic evolution in the treatment of laryngotracheal hemangiomas during the past decade and recent accounts and case reports of propranolol treatment have been encouraging. The purpose of the study is to determine the clinical course and outcomes of treating laryngotracheal hemangiomas at The Children's Hospital of Philadelphia in the last 8 years with the various modalities. We review with contemporary surgical techniques, including propranolol, and determine the results, limitations and complications. The study was a retrospective review of all patients referred to the Otolaryngology service at The Children's Hospital of Philadelphia with symptomatic laryngotracheal hemangiomas between January 2002 and December 2010. The study consisted of 30 infants, ranging in age from 1 to 18 months at time of diagnosis. Surgical interventions included open surgical excision, laser surgery, microdebrider excision and/or propranolol therapy. The main outcome measures include improvement in symptoms, decannulation, number of required treatments and airway size. All but two patients underwent an initial trial of steroids. Thirteen patients underwent open surgical excision, 9 requiring cartilage grafts and 12 were done in a single stage. Twelve surgical patients remained asymptomatic. One patient with diffuse mediastinal disease experiencing postoperative airway symptoms despite a normal appearing airway improved on propranolol. Two patients underwent at least 2 laser ablations, 4 responded to systemic steroids alone, and 1 had microdebrider resection. In the last 14 months, 12 patients have had propranolol therapy at a dose of 2 mg/kg divided every 8 h. Eight patients improved clinically within 1 week of initiating treatment. Four patients failed to respond to propranolol therapy; 1 patient subsequently underwent open excision and the other continued with a tracheostomy for 18 months and finally was decannulated. A third patient had a partial response, but remains relatively asymptomatic. A fourth patient has had no response at all. There were no major complications from propranolol; minor complications included diarrhea and decreased appetite. This study gives an overview of the evolution of hemangioma treatment at our institution over the last 8 years. Surgical excision remains an effective treatment for subglottic hemangiomas. Carefully administered, propranolol may demonstrate efficacy as a first-line agent in most cases avoiding surgery, tracheostomy, prolonged steroids, or as treatment of diffuse and unresectable disease. However, some lesions may be resistant to propranolol and require surgery or long-term steroids.     

Cavernous hemangioma of the tympanic membrane

Cavernous hemangioma seems to most frequently arise in the posterior portion of the external auditory canal. However, they rarely occur in the tympanic membrane. A 49-year-old male patient was referred for evaluation of right-sided pulsatile tinnitus that he'd experienced for the previous 2 years. Temporal bone computerized tomography showed an isolated soft tissue mass just lateral to the tympanic membrane. There was no evidence of bony erosion or middle ear invasion. The patient underwent excision of the mass using a postauricular approach. The mass was removed en bloc and the defect of the tympanic membrane was repaired by tympanoplasty type I. There was no recurrence after 1 year of follow-up.     

下咽癌术中经口使用环形吻合器重建消化道的临床探讨

目的探讨下咽癌术中经口使用环形吻合器连接重建消化道上吻合口的方法及疗效。方法回顾性分析2016年3月~2018年12月因下咽癌就诊于北京协和医院耳鼻咽喉科行手术治疗并于术中经口应用环形吻合器修复口咽缺损的7例患者的临床资料。结果7例患者均未出现咽瘘和上吻合口狭窄。1例于术后19个月因肺部转移死亡,1例于术后9个月出现下吻合口狭窄。 结论下咽癌术中可以经口置入环形吻合器以重建消化道上端,效果较好,术后吻合口瘘、上吻合口狭窄的发生率低于手工缝合,同时更加省时,可靠。关于经口使用环形吻合器的适应证与禁忌证仍需更多的临床探索。     

Diagnosis and treatment of nine cases with carotid artery rupture due to hypopharyngeal and cervical esophageal foreign body ingestion

The aim of our study is to present our experience in the diagnosis and treatment of patients with carotid artery rupture (CAR) due to foreign body ingestion. A total of nine admissions with CAR due to foreign body ingestion were recorded in Second Xiangya Hospital between 1969 and 2011. The carotid artery was sutured with muscle flap coverage in six cases, ligated in three cases. We retrospectively compared different surgical procedures of the patients and their clinical outcomes. Results show that CAR was found in all of these nine cases in imaging examinations or surgery. Among these six patients treated by suture of the carotid artery, five patients had a complete recovery without any complications, one patient underwent common carotid artery (CCA) ligation after suture surgery, but finally died of massive hemorrhage due to uncontrollable infection with carotid artery erosion. Among these three patients treated only by CCA ligation, one patient had no complications, one patient had hemiplegia, and one patient died of severe cerebral edema. Hence, timely diagnosis and open surgery are important for the patients of CAR due to foreign body ingestion. Suture of the carotid artery with muscle flap coverage is a better method compared with ligation of the carotid artery in the treatment of CAR.     

Intramuscular hemangioma of masseter muscle with prominent formation of phleboliths: a case report

A 14-year-old girl was referred for evaluation and management of progressive, painful swelling of the right cheek. Swelling had been present since 3-year old and had gradually increased in size. Magnetic resonance imaging (MRI) revealed a well-circumscribed, brighter mass in the right masseter muscle with numerous rounded areas of signal hypointensity. Preoperative diagnosis was intramuscular hemangioma of the masseter muscle and surgery was performed. The tumor was completely removed except for a few, small phleboliths. Pathological examination of resected tissue led to a high suspicion of cavernous hemangioma with phlebolithiasis. Nine months postoperatively, the patient developed another painful mass in the right masseter muscle. MRI indicated recurrent hemangioma and further surgery was performed. Careful exploration resulted in completely removal of residual phleboliths accompanied with fibroadipose tissue. Part of the buccal branch of the facial nerve was excised to achieve complete resection of the lesion. Histological examination revealed distinct venous formation in phleboliths adjacent to fibroadipose tissue, demonstrating that both phleboliths and feeding vessels had been left by the previous operation. The present report reviews the literature on intramuscular hemangiomas of the masseter muscle, and discusses diagnostic methods and optimal surgical treatment.