Vascular anomalies of the head and neck frequently involve the upper aerodigestive tract and can cause some level of airway obstruction. It is important to fully evaluate the extent of a lesion and resultant functional impairment with a flexible fiberoptic laryngoscopy. Treating these lesions is difficult and considering how to manage the airway during a procedure is critical. A multidisciplinary approach should be used for airway management with alternative intubation plans established prior to induction of anesthesia. Edema and hemorrhage are expected complications from the treatment of vascular anomalies and should be considered when planning for extubation at the end of a procedure.
Key points
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A flexible fiberoptic laryngoscopy should be performed on patients with vascular anomalies to evaluate lesions of the upper aerodigestive tract to understand the full extent of 1 or more lesions.
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Anesthesia and otolaryngology consults should be considered preoperatively for assistance with management of a difficult airway.
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Multiple backup plans should be discussed if intubation is anticipated to be difficult in patients with head and neck vascular anomalies, including alternative intubation methods and awake procedures.
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Edema and hemorrhage should be expected complications following treatment, and a plan for the airway at the end of the procedure should be discussed.
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Laser precautions should be taken when a laser is used for treatment of a vascular anomaly because the head and neck is at higher risk of complications.
Introduction
Vascular anomalies are congenital lesions that can be broadly classified as vascular tumors and vascular malformations. The most common type of vascular tumors are infantile hemangiomas. , Vascular malformations are broadly classified by the type of vessel involved, , which includes capillary, venous, lymphatic, and arteriovenous malformations. Infantile hemangiomas have 3 characteristic phases, including proliferation, plateau, and eventual involution. Vascular malformations are persistent and tend to increase in size with time. , It is important to correctly identify these lesions because they behave differently, as does their treatment.
Head and neck vascular lesions often require a multidisciplinary approach for treatment and special considerations for management of the airway. More than half of vascular lesions occur in the head and neck, and about 40% of venous malformations are seen in the head and neck. Infantile hemangiomas are the most common vascular tumor to involve the airway, and about 60% involve the head and neck. About 73% of patients with head and neck lymphatic malformations will have involvement of the upper aerodigestive tract, most commonly including the tongue, oropharynx, and supraglottis. Multiple sites may be diffusely involved as well and lead to airway obstruction.
Airway Involvement
All of the different types of vascular lesions can affect the airway and disrupt the function of the upper aerodigestive tract, which includes the nasopharynx, oral cavity, oropharynx, supraglottis, glottis, subglottis, hypopharynx, and trachea. Vascular anomalies in these areas can lead to functional complications with speech, mastication, deglutition, and airway obstruction. , , These lesions are most challenging when function is affected, especially the airway. Airway obstruction can manifest in several ways, including stridor, which is a high-pitched noise associated with obstruction at the level of the glottis or subglottis, stertor, which indicates obstruction above the glottis within the nasopharynx or oropharynx, increased work of breathing, tachypnea, retractions, and respiratory failure.
Flexible fiberoptic laryngoscopy
Patients with vascular lesions of the head and neck should have a flexible fiberoptic laryngoscopy performed prior to any planned interventions to evaluate the whole upper aerodigestive tract and lesions that may not be seen externally that could cause airway obstruction. A thorough flexible fiberoptic evaluation should be performed by a provider that routinely performs these examinations. It is better tolerated by patients if the nasal cavities are anesthetized with a topical anesthetic and a nasal decongestant to help constrict the inferior turbinates to allow for easier passage of the fiberoptic scope through the nasal cavities. Allowing 5 to 10 minutes for the medication to take effect is helpful to increase patient tolerance. Bilateral nasal cavities should be evaluated to the nasopharynx. Palate elevation should be documented along with any evidence of velopharyngeal insufficiency as a result of a vascular lesion. Fig. 1 shows an image from a flexible fiberoptic laryngoscopy of a patient with a venous malformation of the nasopharynx that extends to the posterior pharyngeal wall and the base of the tongue. To evaluate the oropharynx, the patient should stick out their tongue to evaluate tongue protrusion and lesions of the base of the tongue, vallecula, and epiglottis. Having the patient cough to clear any secretions and then swallow will allow for evaluation of their swallowing and movement of the epiglottis. Fig. 2 shows a venous malformation that involves the epiglottis, vallecula, and left hypopharynx. To evaluate the hypopharynx, the patient should hold their breath and puff up their cheeks. Voicing tasks, such as phonating “eee”, alternating between a sniff and an “e”, and counting to 10 will allow for evaluation of the movement of the bilateral arytenoid cartilages and true vocal folds along with alteration of the movement by an obstructive lesion. During laryngoscopy, care should be taken to prevent traumatizing lesions so as not to cause bleeding or dynamic changes from coughing or gagging. The size and extent of any lesions along with the involved structures, including proximity to the airway, and alteration of function should be well-documented.
Treatment options
The planned intervention for these lesions depends on correctly identifying the type of lesion, extent and depth of the lesion, and concern for airway obstruction, , all of which can be evaluated on physical examination and flexible fiberoptic laryngoscopy. The management is also dependent on the experience and preference of the treating physicians in a multidisciplinary team. If a patient has laryngeal involvement from a vascular anomaly, then they should undergo a direct microlaryngoscopy for full evaluation of the disease to determine potential treatment options.
There are several options for the treatment of vascular lesions, but they are challenging to treat as patient results vary widely. The main forms of treatment include medical management, sclerotherapy, surgical resection, and laser therapy, or a combination of therapies. Prior to any procedure, it is critical to fully evaluate the patient, their symptoms, and understand the behavior of the lesion being treated.
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Venous malformations are compressible lesions that can fluctuate in size with Valsalva, dependent patient positioning, and increased venous pressure. A patient without airway obstruction and normal respiration in a seated position may develop airway obstruction when recumbent. Up to 70% of patients with head and neck cutaneous venous malformations have involvement of the airway. All patients with cutaneous venous malformation lesions should have a flexible fiberoptic laryngoscopy to evaluate the nasopharynx, oropharynx, and glottis. Venous malformations may involve any part of the upper aerodigestive tract and can have bleeding even with minor manipulation or trauma. Patients with laryngeal involvement may have dysphonia, obstructive sleep apnea (47%–85% of patients), and upper airway obstruction, especially when lying flat.
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Lymphatic malformations may change in size with upper respiratory infections due to inflammation or develop a superimposed infection that can cause airway obstruction and difficulty breathing. These lesions can be microcystic, macrocytic, or mixed. Lesions involving multiple sites may require a tracheostomy for treatment due to the anticipated edema that will result from surgery or sclerotherapy. Medical management of the edema with steroids may be helpful in decreasing the swelling after treatment. , It should be considered to place a drain after a surgical procedure to allow for drainage of any fluid that may persist and decrease the risk of a seroma.
Edema should be anticipated and expected after surgical, sclerotherapy, or laser treatment of venous and lymphatic malformations because the malformations are draining tissues of the head and neck and altering the drainage pattern can lead to swelling. Lymphatic drainage of other sites, such as the oral cavity or oropharynx, can be altered and lead to airway obstruction as well. Anticipation of these complications will help with the postoperative plan, which may be to perform a tracheostomy or keep a patient intubated for a prolonged period of time to allow resolution of the edema or bleeding.
Management of a difficult airway
The basic principles of airway management apply when considering management of head and neck vascular lesions. It is critical to consider how a procedure will affect and alter the airway in order to manage complications. Airway obstruction can occur before, during, or after treatment of a vascular anomaly. Recognizing that a patient may have a difficult airway due to the extent and location of a vascular lesion is key to appropriately managing the airway during treatment, whether that is laser, surgical, or sclerotherapy treatment. Being unprepared for a difficult airway is the main cause of errors in the algorithm for difficult intubation. In 2022, the American Society of Anesthesiologists updated the practice guidelines for the management of the difficult airway. The difficult airway algorithm is shown in Fig. 3 , and can be used as a reference and guide for decision-making for a patient that is anticipated to have a difficult airway for intubation. A multidisciplinary approach should be taken with consultation of anesthesia and otolaryngology for assistance with the management of a possible difficult airway and to prepare a team to manage an anticipated difficult intubation and extubation.
