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Table of Contents
CLINICAL CASES
Year : 2013  |  Volume : 15  |  Issue : 2  |  Page : 38-40

Infantile hemangioma: A case Report


1 European Hoard (ORL & HNS), C.A.B.S (ORL & HNS). DOHNS (UK). Consultant ENT Surgeon
2 Senior ENT Resident
3 ENT Resident. Otolaryngology, Head and Neck Surgery Department, Salmaniya Medical Complex. Kingdom of Bahrain

Date of Web Publication21-Jul-2020

Correspondence Address:
M.D. Habib Husain Merza Abdulkhaleq
P.O. Box: 10508 Manama, Kingdom of Bahrain

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.290347

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  Abstract 


Infantile hemangioma (IH) is a benign neoplasm that commonly develops in neonates within their first few months of life [1]. For reasons that arc not clear, hemangiomas are approximately 3 times more common in female infants and are also more common in whites. Most infantile hemangiomas undergo rapid initial proliferation, with a subsequent plateau in infants aged about 9-10 months; finally, they involute. The involuting phase extends from 1 year until 5 to 7 years of age [2]. Different modalities of management are described in the literature which can be classified as conservative policy, medical treatment and surgical intervention. We present a case of infantile hemcngioma which was managed successfully using medical treatment.

Keywords: Infantile hemangioma. External ear canal, Corticosteroid


How to cite this article:
Merza Abdulkhaleq HH, Alqasim AH, Alwahedi HJ. Infantile hemangioma: A case Report. Saudi J Otorhinolaryngol Head Neck Surg 2013;15:38-40

How to cite this URL:
Merza Abdulkhaleq HH, Alqasim AH, Alwahedi HJ. Infantile hemangioma: A case Report. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2013 [cited 2022 Dec 2];15:38-40. Available from: https://www.sjohns.org/text.asp?2013/15/2/38/290347




  Introduction Top


Occlusion of external ear canal hampers a person’s ability of hearing .There are various causes of occlusion of external ear canal which includes both canal as well as extra-canal conditions. Pre-auricular hemangioma which extends over the tragus and compressing the external ear canal arc a rare condition which if not managed properly ends up with future permanent sequelae.

We report a case of infantile hemangioma which was compressing external car canal and interfering with the hearing ability of infant.


  Case Repotr Top


A six weeks old female infant presented by her parent to our clinic with a history of left side pre-auricular progressive swelling since two weeks. Physical examination showed a peri-auricular swelling on the left side which was soft, superficial and reddish-bluish in color extending to the tragus and compressing the external auditory canal. The tympanic membrane was not visible. [Figure 1]
Figure 1: Infantile hemangioma before initiation of steroid theraphy

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Doppler Ultrasonography of the lesion revealed a superficial hemangioma which was not extending beyond the dermis .We advised for MR! of head, neck, chest and gastrointestinal tract as well as Laryngo- bronchoscopy to roll out presence of other coincidental hemangioma .but the parents did not agree.

Patient started to receive oral steroid therapy as 5mg/ kg/day for four weeks. The dose was reduced gradually over the next 3 months . Renal function tests, serum electrolytes, CBC count, morning Cortisol, and blood sugar were measured at baseline and monthly for 4 months. There were no adverse effects noted during steroid therapy.The size of the hemangioma has reduced significantly and compression over the external canal released. The tympanic membrane became visible by otoscopic examination which was intact without abnormality. Hearing assessment test for her was normal.


  Discussion Top


Infantile hacmangioma is a common problem. In a study of 900 patients, infantile hacmangioma accounted for 25% of soil tissue tumours [3].

There is female predisposition especially lor syndromes associated with hacmangioma [4]. Most hemangiomas are easily diagnosed by thorough history and physical examination. Additional diagnostic tests such as ultrasound or magnetic resonance imaging MRI may be helpful in certain doubtful cases to confirm the diagnosis. The natural course of immature hacmangiomas in infants is well known.

The characteristic MRI findings include a focal, lobulated soft-tissue mass that is isointense relative to muscle on T[-weighted images and hyperintense on T2-weighted images. It has a diffuse and homogenous contrast enhancement and dilated feeding and draining vessels within and around the mass [5]. On ultrasound examination . high vessel density and high peak arterial Doppler shift can be used to distinguish haemangiomas from other sofi-tissue masses with high sensitivity and specificity [6].

Since most of these lesions remain asymptomatic and resolve spontaneously, conservative management is generally the rule [7]. The size and position of the 1H and wither it cause functional impairment or cosmetic issues, play an important role in deciding for treatment modalities.

Despite recent advances, treatment modalities for infantile hemangioma need more randomized, controlled trials to guide physicians to the best treatment options. Nevertheless, current treatment options for problematic haemangiomas include medical care, surgical care or combination of both. Medical care of clinically significant hemangiomas has been limited to a few medications, including glucocorticosteroids (topical, intralesiouai, and oral), interferon alfa, and, rarely, vincristine and topical imiquimod [8].

Recently, Beta-blockers, most specifically propranolol, have been shown to induce involution of infantile hemangiomas. The mechanism of action is unknown; however, some hypothesize that local vasoconstriction may be a factor, which is based on the earlv color change and softening of the lesion [9]. Although propranolol has rapidly been adopted: there is significant uncertainty and divergence of opinion regarding safety monitoring and its dose escalation [10].

Systemic corticosteroid treatment has been established as one of the efficient medical therap> for common cutaneous infantile hemangiomas since a longtime [11],[12].

Oral and intralesional corticosteroids arc effective at slowing the grow th and decreasing the size of proliferating infantile hemangiomas [13]. The mechanism of action has not been elucidated completely: however, corticosteroids have been shown to inhibit VEGF-A expression and subsequent proliferation in hemangioma stem cells in a murine hemangioma model [14].

There is a wide variation in response rates, from less than 40% to greater than 90%. depending on dose. duration of treatment, and age at which corticosteroids are initiated [12]. The meta-analysis of literature shows that the average cumulative response rate is 84% after 2-months therapy with standard doses of oral corticosteroids [11].

It has been demonstrated that higher doses (5 mg/kg/d) have a greater response rate than moderate doses (3 mg/ kg-‘d). [11],[15]

In our case, treatment with 5 mg/kg/daily methylprednisolone for four weeks was initiated; this dose was followed by a tapering schedule over 3 months to prevent rebound. Renal function tests, serum >electrolytes, CBC count, morning Cortisol, and blood sugar were measured at baseline and monthly for 4 months. .No significant adverse effects of steroid therapy were noticed .At the end of the fourth month of therapy the aesthetic results were estimated as good with significant involution of the hemangiomas and full visualization of the external canal and tympanic membrane. [Figure 2]
Figure 2: Result at the end of fourth months of steroid theraphy

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  Conclusion Top


Oral corticosteroid treatment is an efficient medical therapy for infantile hemangiomas with accelerates growth if initiated early in the proliferative phase.



 
  References Top

1.
Barnes CM, Christison-Lagay EA, Folkman J. The placenta theory and the origin of infantile hemangiomas. Lymphat Res Biol. 2007; 5(4):245-255.  Back to cited text no. 1
    
2.
Infantile Haemangiomas and Other Vascular Tumours. Harper’s Textbook of Pediatric Dermatology, Volume 1, 2, Third Edition. Anna L. Bruckner, Ilona J. Frieden, Pages: 113.1-113.28,2011.  Back to cited text no. 2
    
3.
Coffin CM, Dchncr LP,Vascular tumors in children and adolescents: a clinicopathologic study of 228 tumors in 222 patients. Ann Pathol. 1993; 28<Pt 1):97-120.  Back to cited text no. 3
    
4.
Gorlin RJ, Kantaputra P, Aughton DJ, Mullikcn JB: Marked female predilection in some syndromes associated with facial hemangiomas. Am J Med Genet. 1994; 52:130-5.  Back to cited text no. 4
    
5.
Burrows PE, Laor T, Paltiel H, Robertson RL: Diagnostic imaging in the evaluation of vascular birthmarks. Dermatol Clin. 1998; 16:455-88.  Back to cited text no. 5
    
6.
Dubois J, Patriquin HB, Garel L, Powell J, Filiatrault D, David M, Grignon A: Soft-tissue hemangiomas in infants and children: diagnosis using Doppler sonography. AJR Am J Roentgenol. 1998; 171:247-52.  Back to cited text no. 6
    
7.
Ccisler EJ, Santos L, Blei F: Periocular hemangiomas: what every physician should know. Pcdiatr Dermatol. 2004;21:1-9.  Back to cited text no. 7
    
8.
Frieden IJ, Eichcnficld LF, Esterly NB, Gcronemus R, Mallory SB. Guidelines of care for hemangiomas of infancy. American Academy of Dermatology Guidelines/Outcomes Committee. J Am Acad Dermatol. Oct 1997; 37(4):63I-7.  Back to cited text no. 8
    
9.
Sommcrs Smith SK, Smith DM. Beta blockade induces apoptosis in cultured capillary endothelial cells. In Vitro Cell Dev Biol Anim. May 2002; 38(5):298-304.  Back to cited text no. 9
    
10.
Drolct BA, Frommelt PC, Chamlin SL. Haggstrom A, Bauman NM, Chiu YE, Chun RH. Garzon MC, Holland KE, Liberman L, Maclellan-Tobcrt S, Mancini AJ, Metry D, Puttgen KB, Secfcldt M, Sidbury R, Ward KM. Blei F, Baselga E, Cassidy L, Darrow DH, Joachim S, Kwon EK, Martin K, Perkins J. Sicgel DH. Boucek RJ, Frieden IJ : Initiation and use of propranolol for infantile hemangioma: report of a consensus conference. Pediatries. 2013 Jan; 131(1): 128-40.  Back to cited text no. 10
    
11.
Bennett ML, Fleischer AB Jr, Chamlin SL, Frieden IJ. Oral corticosteroid use is effective for cutaneous hemangiomas: an evidence-based evaluation. Arch Dermatol. 2001; 137: 1208-13.  Back to cited text no. 11
    
12.
Zvulunov A, Mctzkcr A. Hemangiomas and vascular malformations: Unapproved treatments. Clinics Dermatol. 2002; 20: 66(1-7.  Back to cited text no. 12
    
13.
Roberts LJ. Management of hemangiomas. Pcdiatr Dermatol. 1997;[4(l):57-83.  Back to cited text no. 13
    
14.
Greenbergcr S, Boscolo E, Adini I, Mulliken JB, BischotT J. Corticosteroid suppression of VEGF-A in infantile hemangioma-dcrived stem cells. N Engl J Med. 2010; 362(11): 1005-13.  Back to cited text no. 14
    
15.
Sadan N. Wolach B. Treatment of hemangiomas of infants with high doses of prednisolone. J Pediatr. 1996; 128: 141-6.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]



 

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