The treatment of hemangiomas and vascular malformations should be individualized, based upon the size of the lesion(s), morphology, location, presence or possibility of complications, the potential for scarring or disfigurement, the age of the patient, and the rate of growth or involution at the time of evaluation. The major challenge is the location in a head and neck can lead to unsightly scars if approached improperly, or with inadequate approaches can lead to intraoperative and postoperative morbidity with neurovascular damage and inadequate lesion excision. Facial, trigeminal, and other cranial nerve branches are of key importance in the functional outcome while accessing and approaching head and neck vascular lesions.
Key points
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Most vascular relations at some stage require surgical intervention status post-medical or interventional radiological therapy.
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Surgery has its challenges considering the location and access to most head and neck lesions.
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“Nidus” management by complete excision is the key to a high vascular lesion. The terminal feeders need to be occluded with litigation or deposition of any embolic material.
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Most of the tongue lesions present as low-flow lesions of a veno-lymphatic type and are rarely high-flow.
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Pericapsular dissection of a low-flow lesion is planned well with intralesional thrombotic agent injections and other interventional radiological techniques.
Introduction
This is a series of 6 cases representing the different management approaches to vascular lesions. The head and neck surgical subsites have been well represented with low flow and high flow and some distinct case theories that contribute to the presentation of the vascular lesion workup, approaches, and outcomes.
Case 1
Low-flow vascular malformation of tongue
Presentation
A 59-year-old man presented with an enormous swelling of the tongue for 25 years. The swelling had started causing difficulty in swallowing and speech. He reported occasional episodes of bleeding which were controlled with local measures ( Fig. 1 A–D ).
Investigation
MRI confirmed isolated involvement of tongue to determine the posterior extent of the lesion with little extension. Doppler and MRI confirmed low-flow vascular lesion.
Treatment
The patient underwent anterior glossectomy with wide excision after collapsing the lesion with bilateral Satinsky vascular clamps applied on the tongue (see Fig. 1 B) to compress the lesion thus aiding in limiting blood loss during surgery. Local oversewing and debulking of the lesion were carried out with monopolar cautery and usage of atraumatic resorbable sutures. He was on nasogastric feeds until swallowing, and speech therapy was given. He was discharged and routine follow-up showed considerable improvement in his swallowing and speech.
This case illustrates how a lesion involving an isolated unit such as the tongue or lip can be managed with corseting and excision ( Fig. 1 A–E).
Learning points
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According to the authors’ (Nair and colleagues) classification, , the aforementioned patient has a type I mucosal lesion.
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They are easy to diagnose as they frequently present with a bluish discoloration commonly seen with diffuse swelling.
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Most of these lesions can be completely excised in toto.
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Well-circumscribed tongue lesions are removed completely or debulked while trying to preserve the form and function of the tongue.
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Access through a V-shaped incision with the help of C or angled clamps not only helps in hemostasis but also enables primary closure. ,
Case 2
Low-flow vascular malformation of the cheek
Presentation
A 7-year-old child presented with swelling over the left side of his face. The swelling was soft, compressible, and non-pulsatile as a solitary mass ( Fig. 2 ).
Investigation
One of the few lesions where computed tomography (CT) could be helpful for diagnosis, a CT angiogram suggested a low-flow lesion involving the subcutaneous tissue overlying the left parotid and angle of the mandible (see Fig. 2 B, C). The presence of phleboliths and details of feeding arteries were reviewed; nidus and draining veins were ruled out.
Treatment
Considering the risk of damage to the facial nerve, it was decided to attempt conservative management with bleomycin. Ultrasound-guided injection was done to confirm the intralesional deposition of the drug. A 3-way syringe with a low caliber hypodermic needle is introduced into the lesion under ultrasound guidance. An amount of blood equal to the amount of drug to be administered is aspirated, and the precalculated dose of bleomycin is administered intralesionally.
2 such injections were performed with a gap interval of 3 months into the lesion (see Fig. 2 E).
In 6 months, the lesion was almost completely resolved.
A 5-year follow-up has shown no recurrence (see Fig. 2 D).
In this case where the lesion is small, intralesional bleomycin using ultrasound was used for minimal morbidity and scarring.
Learning points
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Venous malformation usually presents as a symptomatic soft tissue mass.
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Though ultrasound is a useful tool in treating these lesions, a combination of ultrasound and CT angiography makes the dynamics of vascular malformations clearer.
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Bleomycin inhibits DNA synthesis and has a nonspecific inflammatory reaction on the endothelial cells.
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Though known to cause pulmonary fibrosis, the overall response is favorable.
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Intralesional injection of 15 IU bleomycin in 5 mL of fresh normal saline administered every 15 days for 3 to 4 sittings shows good result. , ,
Case 3
Low-flow vascular malformation of the face
Presentation
A 50-year-old man presented with a diffuse swelling over the right side of his face, progressively getting larger and more painful ( Fig. 3 A).
Investigation
A CT angiogram showed a low-flow lesion with multiple vascular channels involving the cheek, masseter, and parotid gland along with multiple phleboliths ( Fig. 3 B).
The presence of phleboliths within a soft tissue mass on CT is a characteristic of venous malformation. The serpiginous enhancement involving multiple compartments is suggestive of low-flow vascular malformation. ,
Treatment
A preauricular incision with a cervical extension was used to access the lesion. Wide excision and corseting to strangulate the deeper part of the lesion was done to reduce the bulk of the lesion. Placement of a bioresorbable suture (polydioxanone) in a continuous vertical looping fashion constricts the tumor thus obliterating the blood circulation. The excess skin was then excised to achieve closure ( Fig. 3 C–F).
Outcome
The lesion reduced in size considerably in 3 months.
There was transient facial palsy which resolved in 6 months.
Learning points
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Low-flow lesions involving more diffuse areas where complete excision is not possible can be managed with a combination of excision and corseting sutures to reduce morbidity.
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Corset suturing is a proven technique, especially where important structures like the facial nerve are involved. ,
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Large lesions require further excision and debulking as age advances and lesions linger.
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Large low-flow lesions have a potential to be completely removed at a second stage once shrinkage is achieved by corseting.
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Noncapsulated lesions are then rarely excised completely but improve the quality of life and reduce the risk of mortality due to pressure symptoms on the airway and hemorrhage.
Case 4
High-flow lesion of lip
Presentation
A 60-year-old man presented with a pulsatile swelling of the lower lip with occasional bleeding for which he had to get emergency surgical treatment ( Fig. 4 ).
