Intralesional photocoagulation of vascular anomalies of the tongue

British Journal of Plastic Surgery (1999), 52, 178–181 © 1999 The British Association of Plastic Surgeons

Intralesional photocoagulation of vascular anomalies of the tongue C.-J. Chang, D. M. Fisher* and Y.-R. Chen Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan; and *Department of Plastic Surgery, Hospital for Sick Children, Toronto, Canada SUMMARY. Vascular anomalies remain a challenge for patients and reconstructive surgeons. Recently, promising results have been reported using intralesional photocoagulation (ILP) to treat large, deep vascular lesions. We report our experience in treating 12 patients with vascular anomalies of the tongue (10 venous malformations and two haemangiomas) using intralesional photocoagulation. All patients were treated with a Nd:YAG (neodymium:yttrium–aluminium–garnet) (1064 nm) laser (Sharplan, Inc., NJ, USA) delivered with a 600 µm optical fibre. Laser power was set at 7 or 10 W, delivered with a pulse duration of 10 s. Laser energy was delivered to all areas of the vascular lesion. Heat, visible shrinkage and firmness of the lesion signalled the end-point of treatment. The mean follow-up period was 9.5 months (range 3–20 months). All patients demonstrated improvement as judged by a clinical assessment of the reduction in lesion size (mean reduction = 87%, range 60–100%). Three patients (25%) had complications attributed to photocoagulation. Energy delivered too superficially resulted in ulceration or scarring. These complications should be avoidable if this potential for harm is kept in mind. Keywords: haemangioma, vascular malformation, tongue, laser.

Patients with vascular anomalies (haemangiomas and vascular malformations) involving the tongue may present with a variety of symptoms. Recurrent minor trauma, usually secondary to biting the tongue, with resultant recurrent bleeding is common. Obstructive symptoms related to the size of the tumour include: difficulties with breathing, chewing, swallowing and speech. Often the main concern is cosmetic. While observation is considered an appropriate course of management, patients continue to seek treatments to relieve them of their symptoms. Vascular malformations of the tongue have been treated by various means including irradiation,1 intra-arterial 5-FU,2 selective embolisation,3 transfixion suture,4 direct excision,5 CO2 laser excision6 and Nd:YAG (neodymium: yttrium–aluminium–garnet) laser photocoagulation.7 More recently, argon8 and Nd:YAG8,9 lasers have been used to deliver intralesional photocoagulation into large and/or deep vascular lesions. We report our experience in treating vascular anomalies of the tongue using Nd:YAG intralesional photocoagulation (ILP).

using a nasotracheal tube. Local anaesthesia (1% lignocaine with 1:100,000 adrenaline) was infiltrated at the site of needle insertion to minimise bleeding. An 18-gauge Angiocath® was inserted through the mucosa of the tip of the tongue to facilitate introduction of the laser fibre. All patients were treated with a Nd:YAG (1064 nm) laser (Sharplan, Inc., NJ, USA) delivered with a 600 µm optical fibre. Laser power was set at 7 or 10 W, delivered with a pulse duration of 10 s. Laser energy was delivered to all areas of the vascular lesion. Heat, visible shrinkage and firmness of the lesion signalled the end-point of treatment. Following removal of the fibre, pressure was applied to the lesion and the entry site was closed if necessary with a simple chromic catgut suture. Total energy delivered was calculated as the product of the power (W), pulse duration (s) and number of pulses. Patients were admitted to hospital for 3–7 days of observation. They were given a cold liquid diet. Patients with massive, vascular, or oropharyngeal lesions remained nasotracheally intubated during the early postoperative period for airway precaution. Entry wounds and any mucosal ulcerations were treated with topical antibiotic–corticosteroid ointment. Patients were followed closely for 1 month and then monthly to determine the response and assess for any complications. Response was determined by one observer (C-JC) by clinical examination and comparisons with photographic records.

Materials and methods The study was a retrospective review of patients’ records. It was limited to patients with vascular anomalies (vascular malformations or haemangiomas) of the head and neck with involvement of the tongue and who underwent ILP (Nd:YAG) treatment of a tongue lesion. All patients were evaluated and treated by a single surgeon (C-JC). All patients were evaluated preoperatively by MRI (magnetic resonance imaging). Patients were admitted to the hospital. All treatments were performed under general anaesthesia

Results The results are summarised in Table 1. Over a 26month period (1 January 1996–1 March 1998), 200 178

Laser of vascular anomalies of the tongue Table 1

179

Summary of intralesional photocoagulation of vascular anomalies of the tongue in 12 patients

Patient

Lesion

Power (W)

Energy (J)

Resolution

Follow-up

1 TC 34 y M 2 CW 29 y M

VM VM

Entire tongue, cheek Tongue base (< 1/2 ), soft palate, pharynx, cheek, neck

7–10 10

19,400 3800

75% 90%

20 months 16 months

3 WL 35 y F

VM

10

7300

90%

14 months

4 CG 28 y F 5 IT 12 y F

VM VM

Extensive hemifacial; tongue (1/2), cheek, submandibular, triangle, infratemporal and temporal fossae Anterior tongue (< 1/2 ) Anterior tongue (< 1/2 ), floor of mouth, lips, cheek

10 7

4000 5040

100% 100%

12 months 11 months

6 GL 11 y M

VM

7

3360

95%

11 months

7 SM 8 y F

H

7

4900

90%

7 months

8 SC

22 y F

VM

10

1800

90%

6 months

9 CJ

21 y F

VM

10

5400

85%

6 months

7

4970

70%

4 months

7

4900

95%

4 months

10

4800

60%

3 months

10 CY 15 m M

H

11 JY

VM

46 y F

12 CC 33 y M

VM

Tongue base (< 1/2 ), pharynx, cheek, lip Anterior tongue (< 1/2 ), floor of mouth, lips, cheek Tongue base (< 1/2 ) Anterior tongue (1/2), floor of mouth, lip, cheek, parotid, mandible Extensive hemifacial; tongue (1/2), lip, floor of mouth, cheek, temporal fossa Anterior tongue (< 1/2), pharynx, cheek Tongue base (< 1/2), floor of mouth, cheek, chin

Complications

Ulceration of tongue base and bleeding requiring surgical control

Scar contracture of oral commissure – revised with Z-plasty

Ulceration – resolved with conservative management

VM = vascular malformation, H = haemangioma.

patients with vascular anomalies underwent ILP treatment at Chang Gung Memorial Hospital. Twelve of these patients had lesions involving the tongue (10 venous malformations and two haemangiomas). In two patients, the lesions were confined to the tongue. The majority of lesions were more extensive and involved the tongue and adjacent structures. The mean age was 23 years (range 15 months–46 years). There were seven females and five males. The mean followup period was 9.5 months (range 3–20 months). All patients demonstrated improvement as judged by a clinical estimate of the reduction in lesion size (mean reduction = 87%, range 60–100%). There was no incidence of airway obstruction. One patient (GL) with an extensive oropharyngeal lesion was kept intubated for airway protection until the third postoperative day. Three patients (25%) had complications. Two patients developed mucosal ulcers. One small ulceration (patient SC) healed spontaneously with conservative wound management. One ulceration (patient CW) involved the tongue base and was a source of continued gradual bleeding. This patient was brought back to the operating room on the fifth postoperative day for control of bleeding, ulcer excision and primary closure. A third patient (IT) with perioral involvement developed a scar contracture of the lateral commissure. This was later revised by Zplasty. There were no postoperative infections. No cases were complicated by optical fibre breakage. Transient taste and sensation disturbances resolved within 1–3 months depending on the location and extent of laser treatment.

Case reports Case 1 A 28-year-old female presented with a tongue mass (Fig. 1A) which had been present since birth. She complained of difficulties with eating and speech. On examination, a mass was present on the right side of the anterior tongue consistent with a venous malformation. MRI demonstrated a 2.5 × 4 cm lesion (Fig. 1B). Energy (4000 J) was delivered into the lesion by ILP (Fig. 1C) with a Nd:YAG laser in pulsed mode. Her postoperative course was uncomplicated. Clinical examination at 3 months demonstrated complete resolution of the mass (Fig. 1D). She is free of her presenting symptoms.

Case 2 A 33-year-old male presented with complaints of sleep apnoea and difficulties with swallowing and speech, secondary to an extensive congenital venous malformation involving the base of the tongue, floor of the mouth, cheek and chin (Fig. 2A, B). The lesion was treated with 4800 J of energy by ILP (Fig. 2C) with a Nd:YAG laser in pulsed mode. His postoperative course was uncomplicated. Clinical examination at 1 month demonstrated incomplete ablation of the mass (Fig. 2D), estimated as a 60% resolution. He was relieved of sleep apnoea and difficulties with swallowing. Speech was improved, but not completely normal.

Discussion The majority of haemangiomas can be managed by simple observation for regression. Treatment is indicated for lesions which obstruct physiological function

180

A

C

British Journal of Plastic Surgery

B

D

Figure 1––Case 1: (A) preoperative; (B) preoperative MRI demonstrates a 2.5 × 4 cm vascular lesion involving the right side of the anterior tongue (black arrowhead); (C) intraoperative; and (D) 3 months following ILP.

(breathing, vision, hearing) or which are complicated (distortion of features, ulceration, bleeding, infection, coagulopathy, or high-output cardiac failure). The response rate to corticosteroid therapy varies from 30%10 to 90%.11 Immature (proliferating phase) haemangiomas are more responsive than mature lesions11 and rebound growth may occur at reduced steroid doses.12 ILP is thought to act via a combination of vaporisation, photocoagulation and thrombogenesis. In our series, all patients responded to ILP. The variability in response was in the degree of resolution, and this may be more related to the technical aspects of the individual cases. ILP is not limited to the proliferating phase, and rebound growth was not observed. If the response is incomplete, then treatment can be repeated. Total excision is the only definitive treatment for venous malformations.12 Surgical excision of benign tongue lesions, however, must be restrained for functional considerations (taste, mastication, deglutition, speech and pleasure). Airway protection is fundamental. ILP offers some potential benefits over surgical excision. The operative field is limited. Incisions are minimal, limited to stab incision(s) for introduction of the optical fibre. Intraoperative and postoperative bleeding should be minimal. Operative time is reduced. Hospital stay is limited to a period of observation for early airway and wound complications. Taste and sensation disturbances resolve within 1–3 months, depending on the location and extent of

treatment. Ultimately, preservation of tongue form and function may prove to be the greatest benefit. Though none of these patients developed any airway compromise, postoperative swelling does occur and close observation during the early postoperative period is essential. Ulceration with bleeding or subsequent scarring may result from ILP that is administered too close to the mucosal surface. We recommend pulsed mode rather than continuous mode because the delivery of energy is more predictable and controlled. In an ongoing study using a bovine liver model, Chang has shown that a single 10 s, 10 W pulse of intralesional Nd:YAG laser energy produces a sphere of tissue damage measuring 0.5 cm in diameter.13 If the tip of the fibre is kept 1 cm from the mucosal surface and if repeated pulses to the same region are avoided, such complications may be prevented. In summary, ILP is an effective treatment modality for vascular anomalies of the tongue. In our experience, postoperative complications (25%) have been related to photocoagulation that has been delivered too superficially, with resultant ulceration, bleeding or scarring. These complications should be avoidable if this potential for harm is kept in mind. Acknowledgements The authors would like to acknowledge the constructive instruction from Bruce M. Achauer MD and Victoria M. Vander Kam RN, BS,

Laser of vascular anomalies of the tongue

A

C

181

B

D

Figure 2––Case 2: (A) preoperative; (B) preoperative MRI demonstrates an extensive congenital venous malformation involving the base of the tongue, floor of the mouth, cheek and chin (black arrowheads); (C) intraoperative; and (D) 1 month following ILP.

CPSN, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California, Irvine, CA, USA.

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of cutaneous hemangiomas: how effective? A report on 24 children. Clin Pediatr 1978; 17: 625–38. 11. Edgerton MT. The treatment of hemangiomas: with special reference to the role of steroid therapy. Ann Surg 1976; 183: 517–32. 12. Mulliken JB. Cutaneous vascular anomalies. In JG McCarthy (ed.) Plastic Surgery. Philadelphia: W. B. Saunders, 1990, Vol. 5; 3191–274. 13. Chang C-J. Laser surgery of hemangiomas. Presented at the First Asia–Pacific Conference on Cutaneous Surgery and Laser Therapy, Hong Kong, 12 December 1997. Manuscript in preparation.

The Authors Cheng-Jen Chang MD, Assistant Professor, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan. David Fisher MB, BCh, FRCS(Can), Craniofacial Fellow, Department of Plastic Surgery, Hospital for Sick Children, Toronto, Canada. Yu-Ray Chen MD, Professor, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan. Correspondence to Cheng-Jen Chang, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, 199, Tung Hwa Northroad, Taipei, Taiwan 105. Paper received 5 August 1998. Accepted 16 November 1998.