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  • A v presentations /certified fixed orthodontic courses by Indian dental academy

    1. 1. Surgical management of vascular lesions of the head and neck: a review of 115 cases INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
    2. 2. SURGICAL MANAGEMENT OF VASCULAR LESIONS OF THE HEAD AND NECK: A REVIEW OF 115 CASES S. C. Nair, N. J. Spencer, K. P. Nayak, K. Balasubramaniam: Surgical management of vascular lesions of the head and neck: a review of 115 cases. Int. J. Oral Maxillofac. Surg. 2011; presented by kishore .k.v p.g i www.indiandentalacademy.com
    3. 3. Abstract.  Vascular anomalies are amongst the most common congenital abnormalities observed in infants and children.  Their occurrence in the head and neck region is a source of functional and aesthetic compromise. This article reviews the surgical management of 115 cases of vascular anomalies involving the head and neck area treated by the authors between 1998 and 2009. It discusses the diagnostic aids, treatment protocol and the results obtained.  A new classification based on the anatomical location and depth of the lesion has been proposed. www.indiandentalacademy.com
    4. 4. This allows guidelines for surgical treatment of the vascular lesions. The complications encountered are discussed. The use of external carotid artery control as opposed to pre-surgical embolization has proved effective and the technique is described. The location and extent of a vascular malformation should dictate the preoperative investigations, surgical procedure and subsequent outcome. www.indiandentalacademy.com
    5. 5. Vascular anomalies are a group of lesions derived from blood vessels and lymphatics, with widely varying histology and clinical behaviour.  They constitute the most common congenital abnormalities in infants and children.  James Wardrop, a London surgeon, first recognized the differences between true hemangiomas and the less common vascular malformations in 1818.  Despite Dr. Wardrop’s work,descriptive identifiers such as Strawberry hemangioma and salmon patch continued to be used until the 1980. www.indiandentalacademy.com
    6. 6. This terminology did not correlate with the biological behaviour or histology of these lesions. In1982, Mulliken and Glowacki greatly advanced the field by introducing a biological classification which differentiated vascular lesions into two distinct entities: hemangiomas and vascular malformations. . The term hemangioma now describes a lesion that is neoplastic,demonstrating endothelial hyperplasia. vascular malformations, conversely, do not demonstrate cellular hyperplasia but display progressive ectasia of abnormal vessels lined by flat endothelial on a thin basal lamina. www.indiandentalacademy.com
    7. 7. A more practical classification integrating their biological behavior with dynamics of flow was later advanced. Existing classification of hemangiomas and vascular malformations. A. Hemangiomas  Superficial (capillary hemangioma) .  Deep (cavernous hemangioma)  Compound (capillary cavernous hemangiomas) www.indiandentalacademy.com
    8. 8. B. Vascular malformations Simple lesions Low-flow lesions  Capillary malformations (capillary hemangioma, port-wine stain)  Venous malformation (cavernous hemangioma)  Lymphatic malformation (lymphangioma, cystic hygroma) High-flow lesions.  Arterial malformation Combined lesions  Arteriovenous malformations.  Lymphovenous malformations.  Other combinations. www.indiandentalacademy.com
    9. 9. The diagnosis of this group of lesions primarily depends on the history of the lesion and the clinical presentation.  Radiographic evaluation may be helpful in determining the exact extent, location and flow dynamics of some lesions. Patients and methods One hundred and fifteen patients treated by the authors between 1999 and 2009 were reviewed retrospectively. Relevant data including gender, age, age at presentation of symptoms, anatomical site of lesion, relevant radiographic investigations and period of follow up were noted . Exclusion criteria included segmental lesions and those associated with syndromes such as Sturge-Weber. www.indiandentalacademy.com
    10. 10. All patients underwent surgery as the principal modality of treatment.  Computed tomography (CT) with contrast,magnetic resonance imaging (MRI) and angiography were used based on the anatomical location and flow dynamics of the lesion. Selective control of the external carotid artery to reduce blood flow into the lesion was used effectively by the author instead of routine preoperative embolization. Technique for external carotid control The external carotid artery (ECA) of the involved side is exposed through a cervical incision, which often forms part of the access for removal of the malformation.  The sternocleidomastoid muscle is retracted posteriorly at the level of the greater cornu of the hyoid bone, exposing the carotid sheath. The external carotid distal to the carotid bifurcation is identified. www.indiandentalacademy.com
    11. 11. . The vessel is snared with a vascular sling passed through a red rubber catheter. Gentle strangulation of the vessel can be accomplished by advancing the catheter. This additional compression of the vessel serves to reduce blood flow to the lesion. The lesion is exposed with great care taken not to disturb the vascular network. Feeding arteries and draining vessels are identified and ligated, permitting total excision of the lesion. The wound is closed primarily with vacuum drains in situ. www.indiandentalacademy.com
    12. 12. The malformations were categorized into five types depending on their anatomy and depth of location in the head and neck region . Type I- superficial lesions requiring excision of skin or mucosa, local or regional flaps have been used in defect reconstruction .  Type II- submucosal lesions require complete excision after elevation of skin flaps  Type III- lymphovenous malformations or venous malformations involving salivary glands ,are excised along with the affected gland .  Type IV- intraosseous lesions require excision with involved bone and reconstruction when required .  Type V - lesions involving deep visceral spaces, such as the temporal or infra-temporal fossa, require mandibular access osteotomy for complete exposure and total excision. www.indiandentalacademy.com
    13. 13. Categorization of vascular malformation based on anatomical presentation. Type I – Mucosal/cutaneous . Type II – Submucosal/subcutaneous . Type III – Glandular . Type IV – Intraosseous . Type V – Deep visceral . This classification helped in determining the surgical approach and reconstruction if necessary for different types of lesion. www.indiandentalacademy.com
    14. 14. Type I low flow cutaneous venous malformation. Type II low flow vascular malformation in the buccal region. www.indiandentalacademy.com
    15. 15. Type III lymphovenous malformation in left parotid gland. Type IV intra bony hi-flow arterial malformation in maxilla. www.indiandentalacademy.com
    16. 16. Type V MRI showing venous malformation in lateral and post-pharyngeal space www.indiandentalacademy.com
    17. 17. Result  Of the 115 patients evaluated, 63 were male and 52 female.  The youngest patient was a 2-year-old girl with a lymphatic mal formation in the parotid region (type III) and the oldest was a 58-year-old male with a venous malformation involving the entire tongue and submandibular region(type II).  The patients, categorized into types with gender distribution.Thirty-eight patients with type I, 44 patients with type II, 12 patients with type III, 11 patients with type IV and 10 patients with type V anomalies were treated successfully by surgical ablation of their vascular lesions. www.indiandentalacademy.com
    18. 18. Patients gender and age according to the types of the various vascular lesions. Type I II III IV V Age (years) 7–44 (24.705) 3–52 (23.27) 2–43 (26.2) 8–49 (22.8) 18–56 (32.8) Female 15 25 7 3 4 Male 23 19 5 8 6 Four patients with type I lesions required reconstruction with local or regional flaps and 2 patients with type IV lesions required reconstruction of resected mandible. Only 88 patients could provide an approximate time of appearance of the www.indiandentalacademy.com lesion.
    19. 19. In 27 patients the lesion had been noticed at birth or soon after. The remaining 61 patients were clinically aware of it shortly before their first surgical visit. . One hundred and eleven patients gained an acceptable aesthetic outcome with a single procedure. www.indiandentalacademy.com
    20. 20. At the authors centre CT scanning with contrast is the most frequently used imaging modality. Type of imaging CTC Type 1 Type 2 Type 3 Type 4 Type 5 32 34 7 2 6 0 1 1 0 0 angiogram 0 5 4 8 4 No imaging 6 4 0 1 0 MRI www.indiandentalacademy.com
    21. 21. Pre-surgical embolization was restricted to two patients and externalcarotid artery control was required in 52 patients. www.indiandentalacademy.com
    22. 22. Complications encountered are listed www.indiandentalacademy.com
    23. 23. Discussion The first public demonstration of ether anaesthesia by William Green Morton in 1846 was for surgical removal of a venous vascular malformation.  Numerous attempts to understand, classify and treat these lesions have met with unpredictable outcomes.  The classification proposed by Mulliken and Glowacki differentiated this group of lesions into the biologically active hemangiomas and inactive vascular malformations. Classification led to improved understanding of the behavior of these lesions.  Timing of treatment could be based on a scientific understanding of the lesion’s biological behaviour rather than clinical appearance or the surgeon’s sense of gestalt. www.indiandentalacademy.com
    24. 24. Subsequently, Mulliken and Kaban introduced the flow dynamics of vascular lesions, describing hi-flow and low-flow vascular malformations. More recently, a practical classification has helped to consolidate all previous classification. The authors have categorized vascular lesions requiring surgery into five types. This simplified categorization provides input into the investigation and effective surgical management of various lesions based on anatomical presentation. www.indiandentalacademy.com
    25. 25. Diagnosis of vascular malformations depends on precise identification, accurate history, physical examination and the proper use of imaging.  Advances in imaging have led to the unnecessary exposure of many lesions. Grey scale ultrasound and Doppler analysis are useful in defining whether the lesion is solid or cystic and in establishing the flow dynamics of a lesion. In evaluating vascular malformations,MRI has a major advantage over CT or angiography in differentiating hemangiomas from the surrounding structures, but its cost and limited availability can restrict its usage .  In the authors’ experience, imaging is restricted to CT with contrast for most lesions for cost reasons. www.indiandentalacademy.com
    26. 26. MRI is restricted to 2 patients and angiography to 18 patients. Angiography, particularly digital subtraction angiography , has a specific but limited role in the diagnosis of vascular lesions. It is restricted to lesions requiring therapeutic endovascular intervention. Selective embolization as a single treatment modality is rarely successful with high flow anomalies because of rapid establishment of new pathways of flow. Ligation of main feeder vessels is also forbidden due to low success rates and its elimination of access for future embolization. www.indiandentalacademy.com
    27. 27. The use of temporary control (ligation)of the ECA instead of presurgical embolization has proven effective in reduction of blood flow to the lesion, allowing effective excision with minimal blood loss.  If blood replacement is required,autologous transfusion is preferred. When embolization is chosen subsequent to digital Subtraction angiography(DSA) it should proceed from distal to proximal thus ablating both the nidus and its source. . Choice of embolic agents is purely the clinician’s preference. Gelfoam, polyvinyl alcohol,silicone fluid and isobutyl-2 cyanoacrylate are commonly used agents. www.indiandentalacademy.com
    28. 28. When embolization is used, surgery is carried out within 24–48 hr to prevent the development of collateral blood supply . The use of presurgical embolization was restricted to two patients with type V (deep visceral) lesions, both of which required ECA control intraoperatively despite embolization. One of these patients presented for surgical management after undergoing emergent embolization. The second presented with both ECAs feeding into the lesion; one was embolized and the other controlled with temporary intraoperative ligation. Sclerotherapy has a promising but limited role in the management of vascularlesions. www.indiandentalacademy.com
    29. 29. Success has been realized in the treatment of macrocystic lesions. The therapy has been less effective in treating microcystic vascular malformations. The different agents used include sodium tetradecyl sulphate (3%), sodium tetradecylacetate and more recently OK 432 (lyophilizedStreptococcus pyogenes treated with benzyl penicillin) . Surgery has been used effectively to eradicate or minimize the lesion in this review of 115 cases. Surgery must be aimed at removal of the entire nidus along with any structure associated with the lesion because any remaining vasculature will probably lead to recurrence. www.indiandentalacademy.com
    30. 30. The proposed anatomical classification was used to help in planning the approach and extent of resection.  Superficial lesions required excision of skin or mucosa with reconstruction using local or regional flaps . lesions involving the parotid or submandibular gland requires excision of the gland with preservation of nerve. Deeper lesions requires access osteotomies for excision Lesions with in the bone, under went bone resection followed with reconstruction www.indiandentalacademy.com
    31. 31. In patient with malformation (AVM) in the mandible, successful replacement of the resected mandible after enucleation of the pathology was performed. Skeletal deformities secondary to lymphangiomas were common and required secondary correction of the skeletal deformity.  The authors’ surgical approach to vascular malformations based on anatomical presentation is given in the table. www.indiandentalacademy.com
    32. 32. www.indiandentalacademy.com
    33. 33. The complications were restricted to morbidity with no mortality.  The most common problem encountered was incomplete excision requiring another operation at a later date.  Temporary paresis of branches of facial nerve and excessive intraoperative haemorrhage were also seen. Excessive haemorrhage was defined as blood loss requiring more than autologous transfusion. www.indiandentalacademy.com
    34. 34. In conclusion, the use of intraoperative control of branches of the external carotid artery has proved a successful, safe and effective method of intraoperative haemorrhage control when removing these potentially bloody lesions. The approach is easy to incorporate into the access necessary to remove the lesion.  An increase in morbidity by this approach was not compared with lesions treated with preoperative embolization. •The present accepted classification attempts to correlate the biological classification,giveb by Mulliken and Glowacki with the flow dynamics of the lesion. www.indiandentalacademy.com
    35. 35. This is helpful in understanding the lesion behaviour. A further categorization of lesions that require operative intervention based on the technique needed for surgical treatment would be helpful to the managing surgeon. The authors describe a simplified algorithm for effective management of vascular lesions requiring surgery .  For example, hemangiomas are treated with a wait and watch policy since they frequently undergo resolution, but vascular malformations causing functional or aesthetic deformity are dealt with at the earliest opportunity. Proper management depends not only on the biological behaviour, but also on site of anatomical presentation. www.indiandentalacademy.com
    36. 36. Presentation of a lesion not only as a venous malformation, but as a type V venous malformation gives the surgeon the additional information needed to plan treatment properly. Adequate imaging techniques are the key to the successful diagnosis and effective treatment of all vascular anomalies. Angiography should be restricted to anamolies requiring endovascular intervention and lesion that may have feeders from the I.C.A. www.indiandentalacademy.com
    37. 37. MRI with fat suppressed images is most effective.  The use of alternative therapy, such as embolization and Sclerotherapy, has an effective but limited role in treating vascular lesions. The use of clinical data with non-invasive imaging techniques, followed by precise surgery has been successful in providing satisfactory treatment in the majority of patients. Segmental and large composite lesions require multiple therapies. Eradication is unlikely with either surgery alone or combination therapies. www.indiandentalacademy.com
    38. 38. DISCUSSION www.indiandentalacademy.com
    39. 39.  Hemangiomas is the term which is used for a wide variety of vascular lesions in olden days ,but know it is confined to benign vascular neoplasm usually encountered in infants and children. www.indiandentalacademy.com
    40. 40. www.indiandentalacademy.com
    41. 41.  Pathophysiology:  Stages of embryonic vascular development  Stage 1: interlacing blood spaces in ithe primitive mesenchyme differentiate in to a primitive capillary net work.  Stage2: primitive capillaries combine into larger plexiform structures.  Stage 3: disappearance of the primitive elements and appearance of vascular stems and capillary beds www.indiandentalacademy.com
    42. 42. www.indiandentalacademy.com
    43. 43.  Focal failure of the developmental sequences with the persistence of the primitive vascular structures resulting in malformations. www.indiandentalacademy.com
    44. 44. SIGNS AND SYMPTOMS Hemangiomas : usually first appear a few weeks after birth and affect the head and neck in most patients. The trunk and extremities are less commonly involved. Hemangiomas look like red, flat or raised, patches or plaques with or without a cluster of superficial veins.Hemangiomas are generally firm and rubbery to the touch. www.indiandentalacademy.com
    45. 45. Hemangiomas www.indiandentalacademy.com
    46. 46. A-v malformations can be divided into4 major types . 1)infantile hemangiomas –benign neoplasam 2)Ateriovenous fistulas - usually acquired lesions. 3)true arteriovenous malformations – congenital anomalies. 4)predominently venous lesions- dysplasia& caverous venous malformations www.indiandentalacademy.com
    47. 47. SIGNS AND SYMPTOMS Vascular Malformations: High-flow Vascular Malformations Arteriovenous malformations (AVMs) are generally present in neonates at birth, but they often suddenly become obvious when the patient is older because of various stimuli such as trauma, pregnancy, or puberty. There are four recognized stages of AVMs: Stage I lesion has a pinkish-bluish stain and warmth. Stage II, the lesion has pulsations, thrill, and bruit. Stage III, the patient has dystrophic skin changes, ulceration, bleeding, and pain. www.indiandentalacademy.com Stage IV, the patient has high-output cardiac failure.
    48. 48. High-flow Vascular Malformations www.indiandentalacademy.com
    49. 49. SIGNS AND SYMPTOMS Vascular Malformations: Low-Flow Vascular Malformations Venous malformations: are congenital lesions but usually become symptomatic in older children or young adults, with bluish skin discoloration, local swelling, and pain. Although venous malformations are considered benign entities, some extensive venous malformations can result in significant morbidity, particularly those in the head and neck (eg, with airway involvement). www.indiandentalacademy.com
    50. 50. venous malformations may be associated with a limb-length discrepancy, particularly if the malformation is large. Venous malformations of the gastrointestinal tract most commonly cause chronic bleeding and anemia. www.indiandentalacademy.com
    51. 51. Low-Flow Vascular Malformations www.indiandentalacademy.com
    52. 52. SIGNS AND SYMPTOMS Vascular Malformations: Low-Flow Vascular Malformations Lymphatic venous malformations (LVMs) consist of mixed clinical and imaging findings of lymphatic malformations and venous malformations. www.indiandentalacademy.com
    53. 53. DIAGNOSIS Most vascular anomalies, particularly the superficial anomalies (eg, capillary malformations port-wine stains) are recognized by simple clinical history and clinical assessment and do not require any imaging studies. However, most anomalies extending into the deep tissues require imaging studies To confirm the initial diagnosis, To determine the extent of the malformation To plan treatment www.indiandentalacademy.com
    54. 54. DIAGNOSIS MRI IS THE IMAGING STUDY OF CHOICE Angio- MRA- CT angio: The gold standard for high-flow anomalies is conventional arteriography,however the new noninvasive angiographic techniques such as magnetic resonance angiography or computed tomographic angiography offer noninvasive assessment of the flow dynamics and vasculature of highflow anomalies (eg, arteriovenous malformation, arteriovenous fistula). Duplex ultrasonography: Portability and availability are the main advantages of ultrasonography compared with MRI. Ultrasonography is commonly used to quickly evaluate anomalies during the patient's initial visit to confirm the suspected diagnosis. It is also used to triage patients and schedule them for appropriate treatment. www.indiandentalacademy.com
    55. 55. TREATMENT Hemangiomas: Most hemangiomas regress gradually and require no treatment. Surgical Treatment: excision of the localised hemangioma Radiotherapy/ Arterial embolization: can be used in selected cases. Medical Treatment The leading pharmacologic agents used for hemangiomas are steroids, either by systemic use or intralesional injection. Angiogenesis inhibitors such as interferon, vincristine, can be used in selected cases. www.indiandentalacademy.com
    56. 56. TREATMENT Low-flow Malformations: Surgical treatment :a few patients with venous malformations can be treated with a simple surgical excision especially if small and dose not involve vital structure. Sclerotherapy: most patients with venous malformation are dependent on sclerotherapy (in which we infuse sclerosant agent into the lesion under various imaging guidance techniques). Currently, the most commonly used sclerosant agent is absolute alcohol. Other, less commonly used agents, include ethanolamine oleate (Ethamolin) and sodium (sotresol). www.indiandentalacademy.com
    57. 57. Treatment of Low-flow Malformations: www.indiandentalacademy.com
    58. 58. TREATMENT High-flow Malformations: Surgical treatment: Small, superficial arteriovenous malformations can be removed surgically. However, Embolization: It has been the only feasible treatment option for most arteriovenous malformations. Embolization, which closes off the arterial feeders of the malformation, is generally effective in arteriovenous malformations to stabilize the malformation. www.indiandentalacademy.com
    59. 59. conclusion Although they often cause significant psychosocial stress for parents and potentially for children, most vascular anomalies are benign conditions and do not require diagnostic tests or treatments. However, some (eg, arteriovenous malformations or large venous malformations) are quite problematic, causing significant discomfort or disability, and they may worsen. Unfortunately, misclassifications or incorrect diagnoses are common and usually a result of the limited experience of the clinicians or radiologists involved in the diagnosis and management. With the appropriate diagnostic workup and therapeutic management, even rapidly progressing malformations can be managed successfully. www.indiandentalacademy.com
    60. 60. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com