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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 125-128

A novel approach in managing an arteriovenous malformation of head and neck region using sclerotherapy


Department of Oral and Maxillofacial Surgery, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India

Date of Submission21-Oct-2019
Date of Acceptance23-Dec-2019
Date of Web Publication31-Jul-2020

Correspondence Address:
Dr. Uday Kiran Uppada
Department Oral and Maxillofacial Surgery, Sri Sai College of Dental Surgery, Vikarabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_29_19

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  Abstract 


Arteriovenous malformations are unusual fast-flow lesions that arise as a result of dysplastic arterial and venous development, with the lack of a normal intervening capillary bed. Treatment options for small and peripheral vascular lesions are numerous in the form of conventional surgical excision, laser therapy, cryotherapy, selective embolization, and sclerotherapy. Less invasive medical treatment in the form of beta-blocker or steroid is also used. We report a patient who was diagnosed with arteriovenous malformation managed with a sclerosing agent in the form of sodium tetradecyl sulfate.

Keywords: Hemangioma, sclerotherapy, vascular diseases, vascular malformation


How to cite this article:
Kiran B S, Uppada UK, Tiwari PK, Rapolu K. A novel approach in managing an arteriovenous malformation of head and neck region using sclerotherapy. J Cleft Lip Palate Craniofac Anomal 2020;7:125-8

How to cite this URL:
Kiran B S, Uppada UK, Tiwari PK, Rapolu K. A novel approach in managing an arteriovenous malformation of head and neck region using sclerotherapy. J Cleft Lip Palate Craniofac Anomal [serial online] 2020 [cited 2020 Aug 8];7:125-8. Available from: http://www.jclpca.org/text.asp?2020/7/2/125/291141




  Introduction Top


Vascular malformations are congenital lesions that occur frequently in the oral cavity, head and neck region. They present clinically as bluish, compressible, and nonpulsatile lesions.[1] various treatment options in the form of laser therapy, embolization, electrocauterization, steroid administration, surgical removal, or sclerotherapy are available depending on the type, location, and depth of the lesion.[2],[3],[4],[5] Several agents are recommended for sclerotherapy among which sodium tetradecyl sulfate is considered to be a better option. It induces extravascular inflammation as well as thrombosis resulting in ischemic necrosis of blood vessels.[6]


  Case Report Top


A female who was in her fourth decade of life reported to our unit with a chief complaint of swelling in the left buccal mucosa since 5 years and difficulty in mastication due to obtrusion of the lesion between teeth. She gave a history of trauma 5 years ago to the left cheek following which she developed the swelling which was initially of peanut size later developed to present size (4 cm × 5 cm). There was no relevant family history. No known drug allergy as given by the patient. There was no history of pain or ulceration in that area.

On examination, there was no gross facial asymmetry extra orally. Intraoral, a solitary oval purple-colored swelling seen on the left cheek/buccal mucosa measuring about 4 cm × 5 cm extending almost to the left upper vestibule and has well-defined borders and nodular/lobulated surface [Figure 1]. On palpation, inspectory findings are confirmed with respect to size and shape. The swelling appeared to be soft, compressible, pulsatile, nontender, and refills immediately on release of compression.
Figure 1: Preoperative view

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Based on the clinical presentation, a provisional diagnosis of venous malformation in the left buccal mucosa was considered. Investigation: ultrasound Doppler revealed a hypoechoic lesion with a suspicious feeder artery at center of lesion [Figure 2] along superior margin with systolic velocity of 43.7 cm/s and end-diastolic velocity is 4.37 cm/s with moderately high vascular supply. On periphery of lesion, two dilated venous channels are noted with velocity of 4–4.5 cm/s. This is suggestive of combined vascular lesion likely arteriovenous malformations of traumatic origin. Contrast-enhanced computed tomography (CT) – shows dense lesion about 31.6 mm × 15.5 mm × 27.3 mm of soft tissue arising from buccal mucosa of the left cheek with a depth of 6.7 mm from the skin surface. The lesion is exophytic and has lobulated margins projecting into the oral cavity medially.
Figure 2: Ultrasonography of lesion

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The patient was subjected to permucosal sclerotherapy. Intralesional injection of 2 ml of 3% sodium tetradecyl sulfate was done [Figure 3]. Blanching over the lesion was noticed. Digital pressure was applied using wet gauze following the injection. Following 2 h postinjection, there was an extraoral swelling with erythema and inflammatory changes noticed around the site of injection. at 24 hr followup, the swelling subsided, but erythematous changes were present around the site of injection [Figure 3]. After 1 week follow-up, the lesion healed completely leaving a blanched area in center of the site of injection. Two and six months follow up showed no residual lesions or signs of recurrence [Figure 4]. A single dose of sodium tetradecyl sulfate was adequate for the complete resolution of the lesion.
Figure 3: Erythema and inflammation 24 h postoperatively

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Figure 4: Six months' postoperative view

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  Discussion Top


One of the frequently encountered congenital lesions in the head and neck region are vascular malformations. They tend to become more prominent with time. Depending on the type of blood vessel involved, they are categorized into arterial, arteriovenous, venous, capillary, and lymphatic malformations. The male-to-female ratio of occurrence is 1:1. There is persistent expansion of the abnormal blood vessel surrounded by squamous endothelial cells, without any cellular hyperplasia.[7]

They are benign lesions that arise due to structural anomalies of vessels. They cause distressing esthetic problems that can affect the social well-being of an individual in addition to causing pain and bleeding akin to hemangioma; these lesions can arise at any anatomical location of the body. They can present clinically at birth, in infancy or adulthood. Most frequently encountered intraoral sites are anterior two-thirds of the tongue, palate, gingiva, and buccal mucosa. Unlike hemangioma, histologically, they do not reveal endothelial proliferation and do not multiply or regress throughout life.[8] There are a numerous treatment modalities put forth for the management of these lesions.[3],[4],[5] Since the treatment option depends mainly on the type, location, and size of lesions, it is essential to arrive at an appropriate diagnosis based on clinical examination. Doppler ultrasound is recommended to aid the clinical examination. It can be supplemented by CT or by magnetic resonance imaging.[8]

Surgical removal of the lesion is a commonly recommended treatment option. Small lesions can be completely excised. However, thorough surgical abolition of extensive oral or facial lesions is difficult without compromising on the function or causing additional disfigurement.[9] Neodymium-doped yttrium aluminum garnet laser therapy can be employed as a viable option.[9] However, its application is limited only for superficial cutaneous lesions due to the risk of damaging the close vital structures in the face.

The demand for less invasive treatments, which can be employed especially in clinical scenarios where the lesion is encroaching onto important anatomical structures or for managing lesions which are small, has resulted in the introduction of sclerotherapy.[10] Various sclerosants recommended for treating these lesions comprise ethanolamine oleate, ethibloc, bleomycin, and sodium tetradecyl sulfate.[11],[12] These agents deliver a stimulus to vascular endothelial intima, thereby inducing an extravascular inflammatory reactions which ultimately cause vascular fibrosis and occlusion.

Sodium tetradecyl sulfate is one such agent which can induce extra-vascular inflammatory reactions and causes vascular fibrosis leading to their occlusion. It has been widely used as sclerosing agent since a very long time in the management of small varicose veins of the legs, as well as venous and lymphatic malformations.[13],[14] It acts in a manner that produces maximum endothelial damage with minimal thrombus formation that eventually leads to fibrosis of the lesion which leads to shrinkage.[15] The vascular luminal obliteration may or may not be permanent.[16]

Since it can induce skin necrosis, allergic, and anaphylactic reactions, it should be used with caution.[15] 0.5–2 ml is the minimum recommended dose. A dose >2 ml is not recommended in a single lesion. In addition to this, 5–7 days of interval time is recommended for repeating the dose.

Any extravasation of the sclerosant from the targeted site can cause tissue toxicity and may lead to local tissue injury. Most adverse effects of sclerotherapy appear during or immediately after the injection. However, there are a few case reports of possible long-term complications in the literature in the form of local skin and mucous ulcerations or extensive swelling.


  Conclusion Top


Sclerotherapy with the aid of sodium tetradecyl sulfate is considered to be a valuable simple, and noninvasive treatment option in the management of arteriovenous malformations in the head and neck region. It is particularly useful in clinical scenarios where the lesion is encroaching onto vital anatomical structures or for managing lesions which are very small.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zheng JW, Zhou Q, Yang XJ, Wang YA, Fan XD, Zhou GY, et al. Treatment guideline for hemangiomas and vascular malformations of the head and neck. Head Neck 2010;32:1088-98.  Back to cited text no. 1
    
2.
Kohout MP, Hansen M, Pribaz JJ, Mulliken JB. Arteriovenous malformations of the head and neck: Natural history and management. Plast Reconstr Surg 1998;102:643-54.  Back to cited text no. 2
    
3.
Hohenleutner S, Badur-Ganter E, Landthaler M, Hohenleutner U. Long-term results in the treatment of childhood hemangioma with the flashlamp-pumped pulsed dye laser: An evaluation of 617 cases. Lasers Surg Med 2001;28:273-7.  Back to cited text no. 3
    
4.
Kim JY, Kim DI, Do YS, Lee BB, Kim YW, Shin SW, et al. Surgical treatment for congenital arteriovenous malformation: 10 years' experience. Eur J Vasc Endovasc Surg 2006;32:101-6.  Back to cited text no. 4
    
5.
Sadan N, Wolach B. Treatment of hemangiomas of infants with high doses of prednisone. J Pediatr 1996;128:141-6.  Back to cited text no. 5
    
6.
Ramírez-Amador V, Esquivel-Pedraza L, Lozada-Nur F, De la Rosa-García E, Volkow-Fernández P, Súchil-Bernal L, et al. Intralesional vinblastine vs. 3% sodium tetradecyl sulfate for the treatment of oral Kaposi's sarcoma. A double blind, randomized clinical trial. Oral Oncol 2002;38:460-7.  Back to cited text no. 6
    
7.
Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: A classification based on endothelial characteristics. Plast Reconstr Surg 1982;69:412-22.  Back to cited text no. 7
    
8.
Dubois J, Garel L. Imaging and therapeutic approach of hemangiomas and vascular malformations in the pediatric age group. Pediatr Radiol 1999;29:879-93.  Back to cited text no. 8
    
9.
Scherer K, Waner M. Nd: YAG lasers (1,064 nm) in the treatment of venous malformations of the face and neck: Challenges and benefits. Lasers Med Sci 2007;22:119-26.  Back to cited text no. 9
    
10.
Hassan Y, Osman AK, Altyeb A. Noninvasive management of hemangioma and vascular malformation using intralesional bleomycin injection. Ann Plast Surg 2013;70:70-3.  Back to cited text no. 10
    
11.
da Silva WB, Ribeiro AL, de Menezes SA, de Jesus Viana Pinheiro J, de Melo Alves-Junior S. Oral capillary hemangioma: A clinical protocol of diagnosis and treatment in adults. Oral Maxillofac Surg 2014;18:431-7.  Back to cited text no. 11
    
12.
Baurmash H, Mandel L. The nonsurgical treatment of hemangioma with sotradecol. Oral Surg Oral Med Oral Pathol 1963;16:777-82.  Back to cited text no. 12
    
13.
Odeyinde SO, Kangesu L, Badran M. Sclerotherapy for vascular malformations: Complications and a review of techniques to avoid them. J Plast Reconstr Aesthet Surg 2013;66:215-23.  Back to cited text no. 13
    
14.
Candamourty R, Venkatachalam S, Babu MR, Reddy VK. Low flow vascular malformation of the buccal mucosa treated conservatively by sclerotherapy (3% sodium tetradecyl sulfate). J Nat Sci Biol Med 2012;3:195-8.  Back to cited text no. 14
    
15.
Alakailly X, Kummoona R, Quereshy FA, Baur DA, González AE. The use of sodium tetradecyl sulphate for the treatment of venous malformations of the head and neck. J Maxillofac Oral Surg 2015;14:332-8.  Back to cited text no. 15
    
16.
Frullini A. New technique in producing sclerosing foam in a disposable syringe. Dermatol Surg 2000;26:705-6.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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