DISCUSSION
Hemangiomas deserve special attention and consideration, not because of their rarity of occurrence but due to the potential of life threating complications such as airway obstruction and hemorrhage. Similar to hemangiomas in other anatomical sites, hemangiomas of the tongue occur at birth or shortly after and grow rapidly up to 6 months of age after which they spontaneously involute.14 The present lesion demonstrated deviation from expected course and instead continued to increase significantly in size with no signs of involution.
The etiopathogenesis of congenital hemangiomas remains unknown. However, theories such as the placenta theory, metastatic theory, progenitor cell theory and the extrinsic factor theory attempt to describe the development of infantile hemangiomas.15 In rare cases, hemangiomas may be found in patients with Sturge-Weber syndrome, Rendu-Osler Weber syndrome and Blue rubber bleb syndrome.16 In majority of cases a diagnosis of a hemangioma is readily arrived at using a characteristic history of the lesion and local examination.17 Radiographic imaging techniques such as Computed Tomography (CT) or MRI are crucial in volumetric analysis of the lesion and assessment of surrounding structures especially when the lesion is large enough to cause airway compromise or displacement of vital structures.12Digital subtraction angiography provides an additional host of information regarding the nature of involved vasculature, intralesional flow rate and is a critical aid during selective embolization.
Management of hemangiomas depend upon factors such as age, size, location, involved vasculature and response to any previous treatment strategies. Numerous conservative approaches may be implemented prior to opting for surgical intervention including corticosteroid therapy, beta blocker therapy, sclerotherapy, cryotherapy and laser therapy.18,19 In the present case the techniques described above could not be used owing to the fact that the lesion was enlarging at a rapid pace and may have compromised the patient’s airway before these conservative measures could produce a substantial reduction in the size of the lesion. Therefore, the decision to embolize the feeder vessels and surgically resect the lesion was made.
Large vascular malformations usually respond well to selective embolization, reducing the lesion’s size significantly to avert life threatening complications.20 This may even reduce the size of the lesion to a point where the need for a surgical procedure is unnecessary.21 However, also embolization in this case did not have the expected results, hence necessitating surgical intervention. Surgical resection of vascular lesions involving the tongue is a dangerous and precarious procedure that may lead to substantial intraoperative hemorrhage and possibly fatality. The tongue is perfused bilaterally by the LA’s which are large caliber branches originating from the external carotid artery and therefore hemorrhage from a vascular lesion involving this region can quickly prove to be lethal.22 In this case, the tender age in association with the size and location of the lesion heightened the risk significantly. However, the danger of airway compromise significantly outweighed the risk of hemorrhage during surgery which determined the decision to continue with the treatment plan.
A modified key hole resection technique was specifically devised to achieve adequate reduction in both transverse and antero-posterior dimensions of the tongue that would allow it to fit in the oral cavity but yet ensure that functionality remained intact.23Intraoperative hemorrhage was encountered (200 cc) despite the pre-operative embolization but was adequately controlled with bimanual compression of the posterior aspect of the tongue and local control with ligation of the offending vessels. Half a unit (250 cc) of packed red blood cells were transfused to compensate for the blood loss. The reason for the hemorrhage could have been attributed to incomplete embolization of all the feeder vessels or presence of a collateral blood supply. Noteworthy, the patient did not present with further complications. After 1 year of follow up, the patient has normal swallowing and respiratory function with better speech articulation.