Cryosurgery Treatment for Venous Hemangioma of
Tongue:
A Case Report
Dr.K.K. Desarda, Dr. Rohan,
.Dr. Nilima, Dr.Sheetal.
ABSTRACT
Hemangiomas
are frequently seen benign tumors which based on vascular tissues. These
lesions are mainly identified in to two groups which are namedas capillary and
cavernous hemangiomas due to vascularization of the lesions.Capillary
hemangiomas consist of small capillary vessels which show lobulesformation.
Cavernous hemangiomas consist of large dilated vessels and theycan reach to
large sizes. Several treatment modalities including sclerotherapy,embolisation,
laser surgery and cryosurgery have been described forhemangiomas. In this
significant case, the cryosurgery treatment of a 32 yearsold female patient who
was suffering from the huge hemangioma in the rightside of her tongue is
presented with complete regression of haemangioma without any tongue deformity
or atrophy.or post op morbidity.
KEYWORDS
Hemangioma, Cryosurgery
Contact Author
Dr.
K.K.Desarda-Prof.Emeritus-& Head ORL KEM Hospital, Pune.
E-mail :
kdesarda@gmail.com
INTRODUCTION
The
author using cryoapplicator of his own modification presents cryosurgery as a
successful surgical technique in cases of haemangiomas involving , tongue and
oral cavity. From 1980 to 2012 in the ENT-Clinic ,KEM Hospital,Pune. Over 60
patients were operated upon using this method. Most of the cases were treated
under local anaesthesia. The results were very encouraging. Total regression of
haemangiomas and regeneration of normal mucosa with no noticeable scar
resulted. A method of cryosurgery especially suitable for very young patients
or for those who are poor risks because of associated disease and advanced age
is suggested.
Hemangiomas
are benign tumors ofvascular tissue which are most likely to be seen at the
head and neck region. They are the most common tumors of the childhood. They
show
higher prevalence in women. Most of these lesions are described hamartomas
instead of tumors. Vast majority of hemangiomas are known to be
regressive(1).Hemangiomas are classified as capillary and cavernouson the basis
of the vascularization system. (1). Capillary hemangiomas consist of small
capillary bodies that organize lobularly. Cavernous hemangiomas consis of wide
and dilated vessels and can reach to large size..Hemangiomas can be encountered
intraorally; on,tongue, anterior gingival and buccal mucosa. Especially the
lesions on the cheeks and tongue can be traumatized by chewing and bleeding can
occur. (1-4).It is known that deep
hemangiomas could be seen as blue-purple lesions during intraoral examination.
For the diagnosis of cavernous hemangiomas, bidigital palpation of the region
and detection of disappearance of the blood due to finger pressure and after
removal of finger pressure observation of revascularization are important
signs. Furthermore, if the lesion has an arterial origin, pulse can be obtained
by finger pressure(1,2).
Although most
hemangiomas of the tongue are asymptomatic, they could sometimes cause
significant bleeding, pain or difficulty in chewing, speaking, and even
swallowing, if they are large enough. Small lesions can be excised with
impunity. Large lesions, if excised by surgery could result in
significant functional disability. This is why several modalities
of less invasive treatment have recently been advocated (Argon laser, Nd:YAG laser,radiofrequency,scelotherapy,
cryosurgery and superselective embolization to avoid functional disability
caused by tissue loss).
Age and
general condition of the patient has great importance as well as the size and
characteristics ofthe lesion in the treatment of hemangiomas. Small lesions can
be surgically excised while larger ones require specific surgical
interventions. These treatment methods are sclerotherapy, embolisation, laser
surgery, radiofrequency and cryosurgery (1-5)
.
Amongest
all modalities Cryosurgery is a very effective method for thetreatment of
intraoral cavernous hemangiomas. It can be applied under basic local
anesthesia. Freezing should be repeated twice for each area for three to five
minutes to ensure adequate effect. The ice ball should extend a little beyond
the limits of the lesion so that about three-quarter of the diameter of the
observed circumference of the frozen tissue will be at a cell lethal
temperature of – 15° C of normal tissue. Sloughing of some of the central
tissue usually takes places at about one week post operatively and healing may
be expected with 4-6 weeks.
CASE REPORT
A 32 year
old female patient presented to ENT dept KEM Hospital Pune who was suffering
from progressive huge swelling on her
right lateral border of tongue,pain while swallowing,distorted speech and at
time occasional bleeding for over six months.She was treated conservatively by
the medical practioner. She was also seen by general surgeon who advised
surgery (hemiglossectomy) which patient refused.
Clinical examination :
Revealed wide, bluish
purple lesion was detected on the right lateral side of the patients tongue
(Figure 1). The signs of revascularization after finger pressure was determined
and no pulsations were obtained from the lesion and the lesion was diagnosed
with hemangioma. Rest of the ENT examination was WNL
.A
clinical diagnosis of tongue haemangioma was confirmed and patient advised for crysurgery treatment,which
she has accepted since it was less invasive procedure.Routine lab study and
general fitness was taken and patient was posted for cryosurgical intervention
.
...
Under
local anaesthesia 10cc (xylocaine + Adr.1:200000) infiltration all around the
haemangiomatous mass was done with 3mm normal tongue margin. Liquid nitrogen
via large contact cryo tip was applied to the entire lesion for 3 to 5 minutes .including
3mm peripheral normal tissue margin (Fig 1 & 2) Following this process, the
area was washed with NaCl 0.9% and the patient was prescribed with antibiotics,
analgesic, anti-inflammatory agents and tantum mouth wash.. Necrotic and
sloughing area were observed in the postoperative first week (Figure 3 & 4 )and
within four to six weeks the lesion was
successfully and completely healed
(Figure 5 & 6)
Pre
operative & post operative results
of cryosurgery in Tongue Venous Haemangioma shown in these pictures.
Cryofreezing of tongue venous Haemangioma
Fig.3. Intra op cryosurgery lesion
Fig.4. Intra op cryosurgery lesion
Fig.5 Post cryosurgery result 4 wks
Fig. Post cryosurgery result 6 wks
DISCUSSION
The
diagnosis and the classification of the vascularmalformations have a great
importance on the treatment plan of the lesions. Mulliken and Glowackiproposed
a terminology for classifying these lesionsthat is based on clinical and microscopic
features(6) .This system broadly classifies vascular lesions into hemangiomas
and vascular malformations. The hemangioma is the true vascular tumor that
results from a neoplastic overgrowth of normal vascular tissue.The hemangioma
grows by endothelial proliferation.In distinction to hemangiomas, vascular
malformation results from abnormal vascular or lymphatic vesselmorphogenesis,
not as the result of abnormal endothelial growth. Hemangiomas are usually
present at birth and can be diagnosed by 1 year, where asvascular malformations
are present at birth but often not diagnosed until second decade of
life.Hemangiomas show rapid growth until 6-8 monthsand involute by 5-9 year
Vascular malformations show slow growth
throughout life with increase in response to infection, trauma, or hormonal
fluctuation and they do not involute. Osseous involvement of the hemangiomas is
rare but 35% of the vascular malformations show osseous involvement .A wide
variety of methods are utilized for the treatment of intraoral hemangiomas.
Embolisation
technique which is one of them has been utilized since early nineties. However,
embolisation technique has two major disadvantages. One of these disadvantages
is the risk of embolisation material reaching cranial cavity via external and
internal carotid arteries and the need for an experienced radiologist in order
to perform this procedure. The other disadvantage is the temporary blockage of
flow . It would be proper to utilize this method prior to the surgical excision
of large hemangiomas in order to reduce to risk of bleeding
Another
method for the treatment of hemangiomas is sclerotherapy. In this method, a
sclerotic agent is injected into or peripheral to the vein that the hemangioma
originates from. This method is successfully utilized in the treatment of extra
oral lesions. However, pressured bandage can not be applied to the region after
the injection of sclerotic agent inintraoral lesions. Thus, sclerotherapy is
recommended to be applied together with other treatment methods Subzero temperatures
can cause so-called ‘frosbite’whilst temperatures above the coagulation point of
proteins results in ‘burns’. Thermal surgery employs these effects in carefully
controlled manner: the use of temperatures below freezing point constituting cryosurgery
while heating effects are obtained by theuse of lasers normally functioning in
the infrared range of wavelengths.
The
results of the cryosurgery can be explained as acold-induced coagulative
necrosis.
Cryodestruction of a normal or benign
neoplastic tissue normally requiresthe attainment of a temperature of at least
-15°C (thetemperature at which intracellular ice forms) while total ablation of
malignant tumor tissue calls for somedegree of overkill at level of -50°C .For
the management of oral benign, premalignant and malignant lesions liquid
nitrogen is used as a freezing agent and delivered by either probes or sprays Inthis case, probes are preferred in order to
have limited effect on the lesion.In cryosurgery tissue regeneration is
remarkably betterthan the other surgical techniques. When the body spontaneously
separates the coagulated slough there is a powerful stimulus to cellular
division, hyperplasia and apparent hypertrophy; this may be associated with concomitant
cytokine release .Laser surgery is another effective method used for the treatment
of intraoral hemangiomas But, it has several
disadvantages when compared with cryosurgery. Laser surgery is a much more
complex process compared with cryosurgery
Laser
surgery is a much more complex process compared to cryosurgery and requires
general anesthesia.(5) Nerve damage is less in cryosurgery and regeneration is
quicker.Postoperative scar formation is less in cryosurgery.Laser surgery
application can be hazardous around salivary gland ducts, which should be taken
into consideration. Laser surgery costs much more expensive compared to
cryosurgery. However in laser surgery, postoperative edema is less and the
procedure does not require to be repeated. Additionally, laser surgery is a
faster and more dramatic technique
CONCLUSION
A variety
of methods of treatment are thus available for intraoral hemangiomas. The
majority of theselesions can be regarded as capillary-cavernous hemangiomas. In
this case, cryosurgery was preferred for the treatment of the cavernous
hemangioma since it has multiple advantages like being an easy,
cheap,successful method which can be done under local anesthesia and can be
repeated if required for residual lesion.
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