Management of the Low-Flow Head and Neck Vascular Malformations in Children: the Sclerotherapy Protocol

Abstract

Aim Image-guided sclerotherapy is becoming the preferred treatment for low-flow vascular malformations in head and neck region. The authors review the management protocol for this condition and evaluate its clinical outcomes.

Methods Children with low-flow vascular malformations in head and neck region undergoing sclerotherapy from 2010 to 2013 were reviewed. All patients were assessed by pediatric surgeons and interventional radiologists in the multidisciplinary vascular anomalies clinic. Ultrasonography and intravenous contrast enhanced magnetic resonance imaging were performed preoperatively. Under general anesthesia with endotracheal intubation, sclerotherapy were performed with ultrasonographic and fluoroscopic guidance. Sodium tetradecryl sulfate (STS) foam or ethanolamine was used for venous malformation and doxycycline for lymphatic malformations as primary sclerosants, whereas 98% ethanol was reserved as an adjuvant sclerosant in selected cases of repeated procedures. Perioperative dexamethasone 0.2 mg/kg thrice daily was administered to decrease postsclerotherapy swelling and single dose intravenous mannitol 0.5 g/kg was given to minimize thromboembolic complications. Postoperatively, patients were admitted to intensive care unit for mechanical ventilation under deep sedation for airway protection.

Results Overall 13 children (8 male and 5 female) with a mean age of 25 months (range, 2 mo–11 y) underwent a total of 25 sessions of image-guided staged sclerotherapy. There were five venous and eight lymphatic malformations. Location wise there were eight cervical, one lingual, one parotid, one lip, one facial, and one palatal lesions. Six patients had obstructive airway symptoms. Five patients required staged sclerotherapies from two to six sessions. There were no airway and thromboembolic complications. One patient had bleeding while another had recurrent swelling following sclerotherapy for lymphatic malformations and they were treated by aspiration. Significant size reductions of more than 50% volume were achieved in all patients. All patients with obstructive symptoms showed improvement.

Conclusion Sclerotherapy is a safe and effective treatment for head and neck vascular malformations in children. Routine perioperative protocol is essential to reduce airway and thromboembolic complications. Size reduction and functional improvement occurred in all patients undergoing sclerotherapy.

Keywords

vascular malformations - head and neck - sclerotherapy

• References

• 1 Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg 1982; 69 (3) 412-422
• 2 Ethunandan M, Mellor TK. Haemangiomas and vascular malformations of the maxillofacial region—a review. Br J Oral Maxillofac Surg 2006; 44 (4) 263-272
• 3 Jackson IT, Carreño R, Potparic Z, Hussain K. Hemangiomas, vascular malformations, and lymphovenous malformations: classification and methods of treatment. Plast Reconstr Surg 1993; 91 (7) 1216-1230
• 4 Puig S, Casati B, Staudenherz A, Paya K. Vascular low-flow malformations in children: current concepts for classification, diagnosis and therapy. Eur J Radiol 2005; 53 (1) 35-45
• 5 Lee BB. New approaches to the treatment of congenital vascular malformations (CVMs)—a single centre experience. Eur J Vasc Endovasc Surg 2005; 30 (2) 184-197
• 6 Kane WJ, Morris S, Jackson IT, Woods JE. Significant hemangiomas and vascular malformations of the head and neck: clinical management and treatment outcomes. Ann Plast Surg 1995; 35 (2) 133-143
• 7 Greene AK, Burrows PE, Smith L, Mulliken JB. Periorbital lymphatic malformation: clinical course and management in 42 patients. Plast Reconstr Surg 2005; 115 (1) 22-30
• 8 Léauté-Labrèze C, Dumas de la Roque E, Hubiche T, Boralevi F, Thambo JB, Taïeb A. Propranolol for severe hemangiomas of infancy. N Engl J Med 2008; 358 (24) 2649-2651
• 9 Hyder SM, Huang JC, Nawaz Z , et al. Regulation of vascular endothelial growth factor expression by estrogens and progestins. Environ Health Perspect 2000; 108 (Suppl. 05) 785-790
• 10 Berenguer B, Burrows PE, Zurakowski D, Mulliken JB. Sclerotherapy of craniofacial venous malformations: complications and results. Plast Reconstr Surg 1999; 104 (1) 1-11 , discussion 12–15
• 11 Werner JA, Eivazi B, Folz BJ, Dünne AA. State of the art of classification, diagnostics and therapy for cervicofacial hemangiomas and vascular malformations [in German]. Laryngorhinootologie 2006; 85 (12) 883-891
• 12 Eivazi B, Ardelean M, Bäumler W , et al. Update on hemangiomas and vascular malformations of the head and neck. Eur Arch Otorhinolaryngol 2009; 266 (2) 187-197
• 13 Meyer JS, Hoffer FA, Barnes PD, Mulliken JB. Biological classification of soft-tissue vascular anomalies: MR correlation. AJR Am J Roentgenol 1991; 157 (3) 559-564
• 14 Abernethy LJ. Classification and imaging of vascular malformations in children. Eur Radiol 2003; 13 (11) 2483-2497
• 15 Wiegand S, Eivazi B, Zimmermann AP, Sesterhenn AM, Werner JA. Sclerotherapy of lymphangiomas of the head and neck. Head Neck 2011; 33 (11) 1649-1655
• 16 Garzon MC, Huang JT, Enjolras O, Frieden IJ. Vascular malformations: Part I. J Am Acad Dermatol 2007; 56 (3) 353-370 , quiz 371–374
• 17 Cavezzi A, Parsi K. Complications of foam sclerotherapy. Phlebology 2012; 27 (Suppl. 01) 46-51
• 18 Dompmartin A, Ballieux F, Thibon P , et al. Elevated D-dimer level in the differential diagnosis of venous malformations. Arch Dermatol 2009; 145 (11) 1239-1244
• 19 Yakes WF, Haas DK, Parker SH , et al. Symptomatic vascular malformations: ethanol embolotherapy. Radiology 1989; 170 (3 Pt 2) 1059-1066
• 20 Takayasu K, Mizuguchi Y, Muramatsu Y , et al. Late complication of a large simple cyst of the liver mimicking cystadenocarcinoma after sclerotherapy. AJR Am J Roentgenol 2003; 181 (2) 464-466
• 21 Siniluoto TM, Svendsen PA, Wikholm GM, Fogdestam I, Edström S. Percutaneous sclerotherapy of venous malformations of the head and neck using sodium tetradecyl sulphate (sotradecol). Scand J Plast Reconstr Surg Hand Surg 1997; 31 (2) 145-150
• 22 Kok K, McCafferty I, Monaghan A, Nishikawa H. Percutaneous sclerotherapy of vascular malformations in children using sodium tetradecyl sulphate: the Birmingham experience. J Plast Reconstr Aesthet Surg 2012; 65 (11) 1451-1460
• 23 Tan KT, Kirby J, Rajan DK , et al. Percutaneous sodium tetradecyl sulfate sclerotherapy for peripheral venous vascular malformations: a single-center experience. J Vasc Interv Radiol 2007; 18 (3) 343-351