Venous malformations (VM) are congenital lesions, frequently affecting the head and neck, with poor respect for tissue planes. Established treatments include observation, sclerotherapy, laser, and surgical resection.1
Lesions affecting the upper airways present unique challenge due to frequent unresectability and difficult access/exposure for alternative standard treatments. We describe our approach of standard endoscopic airway techniques for the administration of advanced treatment modalities including simultaneous laser and sclerotherapy for an extensive airway VM.
Our patient is a 16-year-old female with an extensive multi-spatial VM with associated airway obstruction. The patient suffered from severe obstructive sleep apnea (OSA) and continuous positive airway pressure (CPAP) dependence as a result of airway compression. Direct laryngoscopy and bronchoscopy demonstrated extensive venous staining and large vascular channels of the hypopharynx. Lumenis Nd:Yag laser (Yokneam, Israel) via 550 micron fiber was passed under telescopic visualization. Treatment via previously described “polka dot” technique was performed (15W, 0.5 pulse duration) with immediate tissue response. The largest vascular channel was accessed via 25-gauge butterfly needle. Immediate return of blood following lesion puncture confirmed intralesional placement. Reconstituted bleomycin (1 U/kg; max dose = 15 U per treatment) was injected and hemostasis achieved with afrin pledgets. The patient was intubated overnight. She was extubated the next morning and advanced to a regular diet, discharging post-operative day two. Post-operative flexible laryngoscopy demonstrated significant improvement in the treatment areas, and follow up sleep study demonstrated sleep apnea resolution with liberation of her CPAP therapy.
Venous malformations (VM) are congenital lesions, frequently affecting the head and neck, with poor respect for tissue planes. Established treatments include observation, sclerotherapy, laser, and surgical resection.1
Lesions affecting the upper airways present unique challenge due to frequent unresectability and difficult access/exposure for alternative standard treatments. We describe our approach of standard endoscopic airway techniques for the administration of advanced treatment modalities including simultaneous laser and sclerotherapy for an extensive airway VM.
Our patient is a 16-year-old female with an extensive multi-spatial VM with associated airway obstruction. The patient suffered from severe obstructive sleep apnea (OSA) and continuous positive airway pressure (CPAP) dependence as a result of airway compression. Direct laryngoscopy and bronchoscopy demonstrated extensive venous staining and large vascular channels of the hypopharynx. Lumenis Nd:Yag laser (Yokneam, Israel) via 550 micron fiber was passed under telescopic visualization. Treatment via previously described “polka dot” technique was performed (15W, 0.5 pulse duration) with immediate tissue response. The largest vascular channel was accessed via 25-gauge butterfly needle. Immediate return of blood following lesion puncture confirmed intralesional placement. Reconstituted bleomycin (1 U/kg; max dose = 15 U per treatment) was injected and hemostasis achieved with afrin pledgets. The patient was intubated overnight. She was extubated the next morning and advanced to a regular diet, discharging post-operative day two. Post-operative flexible laryngoscopy demonstrated significant improvement in the treatment areas, and follow up sleep study demonstrated sleep apnea resolution with liberation of her CPAP therapy.
Nd:Yag and sclerotherapy treatment via endoscopic technique for the treatment of hypopharyngeal VM is safe and feasible, and can be quite effective for the management of upper airway venous malformation associated obstructive sleep apnea.
Venous malformations (VM) are congenital lesions, frequently affecting the head and neck, with poor respect for tissue planes. Established treatments include observation, sclerotherapy, laser, and surgical resection.1
Lesions affecting the upper airways present unique challenge due to frequent unresectability and difficult access/exposure for alternative standard treatments. We describe our approach of standard endoscopic airway techniques for the administration of advanced treatment modalities including simultaneous laser and sclerotherapy for an extensive airway VM.
Our patient is a 16-year-old female with an extensive multi-spatial VM with associated airway obstruction. The patient suffered from severe obstructive sleep apnea (OSA) and continuous positive airway pressure (CPAP) dependence as a result of airway compression. Direct laryngoscopy and bronchoscopy demonstrated extensive venous staining and large vascular channels of the hypopharynx. Lumenis Nd:Yag laser (Yokneam, Israel) via 550 micron fiber was passed under telescopic visualization. Treatment via previously described “polka dot” technique was performed (15W, 0.5 pulse duration) with immediate tissue response. The largest vascular channel was accessed via 25-gauge butterfly needle. Immediate return of blood following lesion puncture confirmed intralesional placement. Reconstituted bleomycin (1 U/kg; max dose = 15 U per treatment) was injected and hemostasis achieved with afrin pledgets.
The patient was intubated overnight. She was extubated the next morning and advanced to a regular diet, discharging post-operative day two. Post-operative flexible laryngoscopy demonstrated significant improvement in the treatment areas, and follow up sleep study demonstrated sleep apnea resolution with liberation of her CPAP therapy.
Nd:Yag and sclerotherapy treatment via endoscopic technique for the treatment of hypopharyngeal VM is safe and feasible, and can be quite effective for the management of upper airway venous malformation associated obstructive sleep apnea.
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Gallant SC, Chewning RH, Orbach DB, Contemporary Management of Vascular Anomalies of the Head and Neck—Part 1: Vascular Malformations A Review. JAMA Otolaryngology Head Neck Surg. 2021 Feb 1;147(2):197-206.
Oomen KP, Paramasivam S, Waner M, Niimi Y, Fifi JT, Berenstein A, O TM. Endoscopic transmucosal direct puncture sclerotherapy for management of airway vascular malformations. The Laryngoscope. 2016 Jan;126(1):205-11.
Gregory S, Burrows PE, Ellinas H, Stadler M, Chun RH. Combined Nd: YAG laser and bleomycin sclerotherapy under the same anesthesia for cervicofacial venous malformations: a safe and effective treatment option. International journal of pediatric otorhinolaryngology. 2018 May 1;108:30-4.
Manna S, Meyer A, Shigematsu T, Berenstein A, Courey M. Management of a laryngeal venous malformation with Nd: YAG laser and bleomycin sclerotherapy. The Laryngoscope. 2020 Sep;130(9):2199-201.
Lee DR, Richter GT. Nasopharyngeal venous malformation: a rare condition managed with Nd: YAG laser. The Laryngoscope. 2015 Oct;125(10):2405-7.
Review Endoscopic Nd:Yag and Bleomycin Injection for the management of a Hypopharyngeal Venous Malformation. Cancel reply
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So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
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Review Endoscopic Nd:Yag and Bleomycin Injection for the management of a Hypopharyngeal Venous Malformation.