Management of the Low-Flow Head and Neck Vascular Malformations in Children: the Sclerotherapy Protocol

Abstract

Aim Image-guided sclerotherapy is becoming the preferred treatment for low-flow vascular malformations in head and neck region. The authors review the management protocol for this condition and evaluate its clinical outcomes. Methods Children with low-flow vascular malformations in head and neck region undergoing sclerotherapy from 2010 to 2013 were reviewed. All patients were assessed by pediatric surgeons and interventional radiologists in the multidisciplinary vascular anomalies clinic. Ultrasonography and intravenous contrast enhanced magnetic resonance imaging were performed preoperatively. Under general anesthesia with endotracheal intubation, sclerotherapy were performed with ultrasonographic and fluoroscopic guidance. Sodium tetradecryl sulfate (STS) foam or ethanolamine was used for venous malformation and doxycycline for lymphatic malformations as primary sclerosants, whereas 98% ethanol was reserved as an adjuvant sclerosant in selected cases of repeated procedures. Perioperative dexamethasone 0.2 mg/kg thrice daily was administered to decrease postsclerotherapy swelling and single dose intravenous mannitol 0.5 g/kg was given to minimize thromboembolic complications. Postoperatively, patients were admitted to intensive care unit for mechanical ventilation under deep sedation for airway protection. Results Overall 13 children (8 male and 5 female) with a mean age of 25 months (range, 2 mo-11 y) underwent a total of 25 sessions of image-guided staged sclerotherapy. There were five venous and eight lymphatic malformations. Location wise there were eight cervical, one lingual, one parotid, one lip, one facial, and one palatal lesions. Six patients had obstructive airway symptoms. Five patients required staged sclerotherapies from two to six sessions. There were no airway and thromboembolic complications. One patient had bleeding while another had recurrent swelling following sclerotherapy for lymphatic malformations and they were treated by aspiration. Significant size reductions of more than 50% volume were achieved in all patients. All patients with obstructive symptoms showed improvement. Conclusion Sclerotherapy is a safe and effective treatment for head and neck vascular malformations in children. Routine perioperative protocol is essential to reduce airway

Intramuscular Vascular Malformations

“…Doxycycline is often the primary sclerosant used in lymphatic malformations 22 and has been gaining popularity as a sclerosant because of its low cost, availability, and safety profile. 22,23 In cases of lymphatic malformations, success rates of 67% to 100% have been reported with doxycycline. 11,22,23 Doxycycline sclerotherapy has also been used successfully in Morel-Lavallée lesions, pleural effusions, and mixed capillary and lymphatic malformations.…”

Guidelines and parameters: percutaneous sclerotherapy for the treatment of head and neck venous and lymphatic malformations

“…Some authors have advocated the use of intravenous mannitol at a dose of 0.5 g/kg to maximally expand the intravascular volume prior to performing sclerotherapy 25. Additionally, steroids, such as dexamethasone at a dose of 0.1–0.2 mg/kg three to four times daily for 1–2 weeks, may be administered to minimize swelling and reduce pain periprocedurally 25 30 62 63.…”

“…The majority of VM and LM present perinatally or in early childhood, and the most common presenting symptoms include: (1) swelling, (2) pain secondary to mass effect on the adjacent soft tissues or nerves, (3) infection, (4) difficulty in breathing or dysphagia secondary to mass effect on the oropharynx, (5) visual deficits, and (6) auditory deficits 3 8 25. Pediatric patients with VM or LM are also frequently brought to clinical attention with cosmetic concerns on behalf of their parents or caregivers.…”

A New Method for Using Radiopaque Sclerosing Foam to Treat Venous Malformations

“…[2][3][4] Polidocanol (POL) and sodium tetradecyl sulfate are the most common agents for sclerosing foam preparations, [5][6][7][8][9] which perform with better potency than liquids for venous anomalies. 10 Guided visible foam sclerotherapy for VMs with ultrasound or digital subtraction angiography (DSA) has become a research focus and academic front contributing to its accuracy and safety.…”

“…10 Guided visible foam sclerotherapy for VMs with ultrasound or digital subtraction angiography (DSA) has become a research focus and academic front contributing to its accuracy and safety. 5,[11][12][13][14][15] The ultrasonography is limited to detecting the venous outflow and extravasation of sclerosing agents and requires special skills of operators. 16 However, foam flows can be traced with a "filling defects" technique under DSA.…”