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.