Hemangioma is a benign tumor formed by blood vessels. The Greek suffix “oma” means cell proliferation of a tumor, and “hemangioma” is related to blood vessels. So, hemangioma refers to a tumor of the blood vessel. They are most commonly seen in pediatric groups and are generally benign. They first go through a proliferative phase in which hemangiomas undergo rapid proliferation during the first weeks/months of life and last between 12 and 18 months. Later, in the involution phase, the size decreases and complete resolution can take up to 12 years. In adults they can occur at any age and do not follow the proliferation and involution phases. In infants, laryngeal hemangiomas are almost exclusively of the capillary type. They typically involve the subglottis, the narrowest portion of the pediatric airway. , whereas, in adults, they are more commonly found in the supraglottis. Since most laryngeal hemangiomas in children regress over time, they do not need treatment. In adults, treatment is usually required. This article discusses the rare case of recurrent laryngeal hemangioma in an adult woman and its treatment.
An otherwise healthy 18-year-old girl began complaining of shortness of breath after exercise and a change in her voice for three months. The shortness of breath has gotten worse over the past month, even with light to moderate walking. She had no history of smoking, infection, previous intubation, trauma, or excessive use of voice. Her physical examination, blood tests, and her chest X-ray all came back negative. X-ray of the soft tissues of the neck
shows a well-delimited space-occupying lesion in the region of the vocal cords. A polypoid lesion was visualized with direct laryngoscopy. On multislice computed tomography (MSCT), a well-defined polypoid soft-tissue lesion of the true vocal cord was identified involving the posterior commissure on the left side and projecting into the rhyme-glottis, narrowing the airway. The size of the lesion was 12.5*9*10 mm.
Tracheotomy and laryngeal microsurgery with coablation were performed under general anesthesia. The pathology report identified capillary-type vascular proliferation -hemangioma- in the supraglottis. On postoperative day 5, the tracheostomy tube was removed and she was discharged. But the next day, the patient was readmitted with complaints of dyspnea and was taken to direct laryngoscopy with removal of slough and reinsertion of the tracheostomy tube. The histopathology report showed a post-surgical reaction. A follow-up MRI two months later showed the size of the lesion to be 10 x 6 x 7 mm.
After five years, the patients began to develop shortness of breath on exertion. Magnetic resonance imaging showed an increase in the size of the hemangioma to 10*13*13 mm at the level of the posterior commissure in the midline with projection in the laryngeal ventricle and supraglottic larynx. His symptoms continued to worsen and a repeat MRI showed an increase in the size of the lesion to 11*14*15 mm (fig. 1). Microlaryngoscopy for biopsy and CO cytoreductiontwo the laser was done. Biopsy results showed lymphoplasmacytic cell infiltrate with a thin-walled capillary. After three months, the patients began to feel short of breath. Magnetic resonance angiography showed an increase of the supraglottic laryngeal hemangioma to 13*14*16 mm. It showed a well-defined lobulated submucosal lesion that homogeneously enhanced at the level of the posterior commissure in the midline that projected into the laryngeal ventricle and the supraglottic larynx and bordered on the inferior aspect of the left aryepiglottic fold, as shown in the video. 1compatible with a hemangioma. Angiography showed a small ductus arteriosus in the posteroinferior aspect of the lesion, possibly originating from a branch of the superior thyroid artery. A tracheotomy was performed with reduction of the laryngeal mass. Video two Shows endoscopy after surgery. A follow-up MRI three months later showed a residual lesion of size 4.9*4.4*6 mm.
After three months, the patient began to have symptoms. He was having difficulty breathing with a tracheostomy tube in place. Magnetic resonance imaging showed a lobulated submucosal lesion with residual homogeneous signal intensity at the level of the posterior commissure in the midline that projected into the laryngeal ventricle and the supraglottic larynx and bordered on the inferior aspect of the left aryepiglottic fold. A videolaryngoscopy showed that the mass in the interarytenoid region extended into the subglottis. Near total removal of the mass with CO microlaryngoscopytwo Laser ablation was performed. The biopsy report showed granulation tissue with proliferation of spindle cells. His last endoscopy is shown below in Figure 3 on the right side. The patient is now symptom free. The patient is recommended to follow up every five years and immediately if any symptoms develop.
Hemangiomas are benign vascular tumors and common childhood tumors. . Hemangiomas can be classified based on histology, anatomic location, or age of onset. Hemangiomas that grow from endothelial cell hyperplasia must be differentiated from localized defects of vascular morphogenesis called vascular malformations. The International Society for the Study of Vascular Anomalies (ISSVA) classified vascular tumors from vascular malformations based on their clinical appearance, radiological features, pathological features, and biological behavior. . Vascular neoplasms have increased endothelial turnover, whereas vascular malformations are structural abnormalities of the capillary, venous, lymphatic, and arterial systems that grow in proportion to the child. According to this classification, hemangioma magnetic resonance angiography shows a well-demarcated tumor with flow voids, while vascular malformation shows hypersignal on T2-weighted sequences and may show heterogeneous signal on T1-weighted magnetic resonance imaging. . Furthermore, the hemangioma appears homogeneous hyperintense on T2-weighted MRI, which is usually isointense compared to T1-weighted MRI. .
In general terms, hemangiomas are true benign vascular tumors characterized by increased vascularity and account for 7% of all benign tumors in infancy and childhood. . Hemangiomas of the larynx can be divided into childhood and adult. Laryngeal hemangioma presents as abnormal crying, persistent stridor, and chronic cough and is accompanied by a skin lesion. . The differential diagnosis of airway obstruction in the pediatric population is laryngomalacia, vocal cord paralysis, subglottic stenosis, laryngeal membrane, laryngeal atresia, laryngeal cleft, laryngeal saccular cyst, and laryngocele. .
As infantile hemangiomas are known to undergo rapid proliferation followed by slow involution, the primary goals of treatment should be to provide an adequate airway during the period of proliferation, avoid life-threatening obstruction, and minimize therapies that can lead to long-term complications. term. Medical treatment of infantile hemangioma includes systemic corticosteroids, which can stop the progression of the hemangioma during the proliferative phase. However, it comes with adverse effects like cushingoid appearance and hypertension. Interferon treatment is reserved for a refractory type of infantile hemangioma. Vincristine has also been used successfully, but only limited data are available. Surgical management includes laser ablation and tracheotomy. . Propranolol has been reported to dramatically reduce the size of cutaneous and airway hemangiomas. As the recommended dose of propranolol is lower than that used in cardiovascular diseases, there are only a few adverse effects. . But watch for bradycardia, hypotension, hypoglycemia, and worsening reactive airway disease. .
Adult hemangiomas are rare and most often cavernous forms. [8,9]. The patient described here had a type of capillary hemangioma, and the capillary hemangioma is well circumscribed and smaller than a cavernous hemangioma.
In an adult, a laryngeal hemangioma can occur at any age. Etiologic factors include smoking, vocal abuse, and laryngeal trauma. There are few or no symptoms associated with it. Although rare, it is usually found at or above the level of the vocal cords. Irritation of the region is the only main symptom. May present as hoarseness, hemoptysis, shortness of breath, dysphagia, aspiration of thin fluids balloon, acute respiratory distress sudden collapse and death . There is no skin lesion present with an adult type of hemangioma. Adult laryngeal hemangioma affects the supraglottic region. Presentation usually includes dysphagia, hoarseness, shortness of breath, and recurrent bleeding. . Treatment options depend on the patient’s age, anatomical location, size, and type of injury. For babies with hemangioma that do not cause symptoms, spontaneous regression can be expected. Adult hemangiomas are generally not progressive, so clinical observation is the best management strategy. . For large or symptomatic hemangioma, systemic steroids, corticosteroid injections, ethanol injections, cryosurgery, radium or gold implants, interferon therapy, laser surgery, and ultrasonic scalpel  can be used [8,14-16].
In one article, a 3 x 2.2 x 2.5 cm hemangioma was removed with CO2 laser in continuous mode and Depo-Medrol (corticosteroids) was injected to reduce the size of the remaining hemangioma. . Although in this case, the hypopharyngeal part of the mass was not treated due to the surgical risks of injuring the large blood vessels. Although there was no recurrence or any complication noted in the 2-year follow-up period. .
Argon plasma coagulation can be used, which has a high safety profile due to reduced penetration depth . A published article on ultrasonic scalpel dissection reported that it is a safe, effective, and less invasive method of treating large laryngeal hemangiomas .
In conclusion, adult laryngeal hemangiomas are very rare. An adult supraglottic hemangioma can be treated in one or more stages with COtwo excision with laser and ultrasonic scalpel. The causes and triggers of recurrence are still unknown. This case report suggests that complete or nearly complete resection is necessary to prevent regrowth. However, few articles have suggested that the use of intralesional corticosteroids after excision can prevent a recurrence. More studies are needed to establish guidelines for the treatment of laryngeal hemangiomas in adults and how we can prevent their recurrence.