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Surgical management of
vascular lesions of the head and
neck: a review of 115 cases
INDIAN DENTAL ACADEMY
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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

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.

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.

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.

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.


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)


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.

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.

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.

.

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.


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.

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.

Type I low flow cutaneous
venous malformation.

Type II low flow vascular
malformation in the buccal region.


Type III lymphovenous malformation in
left parotid gland.

Type IV intra bony hi-flow arterial
malformation in maxilla.


Type V MRI showing venous malformation in lateral and post-pharyngeal space


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.


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
lesion.

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.


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


Pre-surgical embolization was restricted to two patients and
externalcarotid artery control was required in 52 patients.


Complications encountered are listed


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.


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.


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.

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.

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.


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.

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.

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


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.


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.


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.


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.

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.

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.

DISCUSSION


 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.


 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

 Focal failure of the developmental sequences

with the persistence of the primitive vascular
structures resulting in malformations.


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.


Hemangiomas


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


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.
Stage IV, the patient has high-output cardiac failure.

High-flow Vascular Malformations


SIGNS AND SYMPTOMS
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).


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.


SIGNS AND SYMPTOMS
Lymphatic venous malformations (LVMs) consist of
mixed clinical and imaging findings of lymphatic
malformations and venous malformations.


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


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.

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.

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).

Treatment of Low-flow Malformations:


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.

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.

Thank you
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