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

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
partial regression with cosmetically accepted condition and
one patient did not respond to treatment and later managed for
close follow up. Two patients had an ulcer, three patients had
pain, and three patients had localized oedema, at the tongue
but they recovered completely within two weeks.
Hence success rate of the present study was 93%
Fig-1 (Pre Op) Fig-2 (Post Op)
Fig-3(Pre Op) Fig-4 (Post OP)
Discussion
The word "Haemangioma" comes from the greek word –
haema means blood, angio means vessel & the suffix oma
means tumour, as a result it is a blood vessel tumor.It is a
tumor of infancy & most cases appear during the first few
days or weeks of life & resolve within the age of 10
years.Haemangiomas are common lesions of face, nose,
throat, ear, neck, liver and most often seen to involve the lips,
tongue and buccal mucosa. They are classified into three basic
types, capillary haemangioma, cavernous haemangioma and
arterial or plexiform haemangioma. Before considering the
haemangioma, it is important to understand that there have
been changes in the terminology used to define, describe and
categorise vascular anomalies. The term haemangioma was
originally used to describe any vascular tumor like structure,
where it was present at or around birth or appeared in later
life.Haemangiomas are the most common childhood tumor.
Females are five times more likely to have haemangiomas
than males but all our patients are males. They are also
common in twin pregnancies. Approximately 80% are located
on the face and neck, with next the most prevalent location
being the liver 8 The most frequent complaints about
haemongioma, however, stem from psychosocial
complications, the condition can affect a persons appearance
and can provoke attention and malicious reaction from
others.The potential for psychological injury develops from
school age group onwards. It is therefore important to
consider treatment prior to school, if adequate spontaneous
improvement has not occurred. Most haemoagiomas
13 National Journal of Otorhinolaryngology and Head & Neck Surgery, Vol. 1(10) No. 1, April 2013
disappear without treatment, leaving minimal or no visible
marks.
Up until recently, the mainstay of treatment was oral
corticosteriod therapy. Beta blocker treatment using agents
such as propanolol is revolutionizing therapy, producing
impressive responses. A publication in the international
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.
Reference
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
origin of infantile hemangioma". Proc. Natl. Acad. Sci.
U.S.A.102 (52): 19097–102.
3. Hogeling M et al. (August 2011). "A randomized
controlled trial of propranolol for infantile
hemangiomas". Pediatrics 128 (2): 259-266
4. 4. Chaplin M E. Cryosurgery of benign oral lesions. J
Dermatol Surg Oncol 1977;3:428-31.
5. Braun I F, Levy S and Hoffman J C (Jr). The use of
transarterial microembolization in the management of
hamangiomas of perioral region. J Oral Maxillofac Surg
1985;43:39-48.
6. 6. Morreli J G, Tan O T and Weston W L. Treatment of
ulcerated hemangioma with the pulse tunable dye laser.
Am J Dis Child 1991;145:1062-64.
7. Apfelberg D B, Maser M R, Lash H and White D N.
Benefits of the carbon dioxide laser in oral hemangioma
excision. Plast Reconstr Surg 1985;75:46-50.
8. C.M. Branes, S. Huang, A. Kaipainen, et al. "Evidence by
molecular profiling for a placental origin of infantile
Journal of College of Medical Sciences-Nepal, 2012, Vol-
8, No-1 59
9. hemangioma" Proc Natl Acad Sci U.S.A 2005; 102
(52):19097 –102.
Address for Correspondence
Dr Ajay Lavania
Asso. Prof. School of Medical Science & Research,
Greater Noida, U.P.
E mail : ajayent1@gmail.com
Cell : +91 9911363002