Cryosurgery of multiple haemangiomas of oral cavity
- Pavithran Ashokkumar ,
- Pearlcid Siroraj ,
- Giri Govindarajan Valanthan Veda and
- Bala Kiran Vegesana Krishnakumar Raja
- Oral and Maxillofacial Surgery, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, Tamil Nadu, India
- Correspondence to Dr Pearlcid Siroraj; pearlcid@hotmail.com
Abstract
Haemangiomas of the oral cavity are common benign vascular tumours of infancy. Several treatment modalities are described for haemangiomas, including sclerotherapy, embolisation, laser surgery and cryotherapy. Cryotherapy is the application of varying extremes of low temperatures to destroy abnormal tissue. Since cryosurgery is effective, simple and easy to perform, it is used in the treatment of lesions in both medicine and dentistry. Cryosurgery provides many advantages such as easy operation, absence of intraoperative bleeding and low infection rate. In this case, the cryosurgical treatment of a young patient who suffered from multiple haemangiomas of the oral cavity that was refractory to medical treatment is presented.
Background
Haemangiomas are benign tumours of vascular tissue that occur frequently in the head and neck region. Higher prevalence was seen in females in their first and second decade of life. The majority of haemangiomas regress on their own.1 The most common sites of occurrence are lips, tongue, anterior gingiva and buccal mucosa. Lesions of the tongue and cheeks can easily be traumatised by biting habits. Age and general condition of the patient have great importance as well as the size and characteristics of the lesion in the treatment of haemangiomas. Although small lesions are managed easily with excision, larger lesions may require invasive methods. These treatment methods include sclerotherapy, embolisation, laser surgery and cryotherapy.2–5 Cryotherapy is an effective method for the management of intraoral haemangiomas and it can be carried out under local anaesthesia. The procedure is painless, causing minimal damage to adjacent structures.6 7 Cryotherapy can be localised, and it is readily controllable to promote rapid and uneventful healing.6 7 Given the wide applicability of cryosurgery in the field of oral and maxillofacial surgery, we report a case of multiple haemangiomas of the face and oral cavity successfully treated with cryotherapy.
Case presentation
A patient in early adolescence was referred from the Department of Paediatric Surgery to the Department of Oral and Maxillofacial Surgery for an opinion regarding multiple vascular lesions of the oral cavity. The patient gave a history of a small lesion at middle childhood, which continued to grow slowly and asymptomatically, for which the patient consulted a paediatrician and underwent MRI and CT of the head and neck with an initial diagnosis of capillary haemangiomas of the oral cavity. The patient was initially treated with excision of a single lesion in the right commissure of the mouth, which recurred in the following year. At middle childhood, the patient was started with oral propranolol for 6 months. The treatment was discontinued by the physician as there was no response to medical management. She had no familial history. On examination, a total of five purplish, sessile, nodular lesions, firm to palpation, and each measuring about 0.5–1.5 cm in their greatest diameter, were found in the right commissure of mouth, lower lip, floor of mouth proximal to the lingual frenum, the tip of the tongue and right buccal mucosa (figure 1). The lesion on the tip of the tongue caused discomfort to the patient during mastication and speech. All the other lesions were asymptomatic.
Clinical image showing multiple red lesions measuring 0.5–1.5 cm present in the tip of the tongue, floor of the mouth and corner of the mouth.
Investigations
Earlier contrast-enhanced MRI and CT of the head and neck region performed at middle childhood gave a provisional diagnosis of capillary haemangiomas of the oral cavity. Since the imaging modalities have provided us with a diagnosis and the clinical features were consistent with the radiological diagnosis, no differential diagnosis was made. Diascopy was performed by applying pressure on the lesion with a glass slide. It showed an ischaemic lesion pattern. Bloody aspirate was elicited on the fine-needle aspiration that was suggestive of haemangiomatous origin. Excision biopsy was ruled out because of the vascular nature of the lesions and the significant postoperative morbidity involved with the procedure. Cryosurgery using nitrous oxide gas under local anaesthesia was chosen as a definitive treatment option. Prior to the initial procedure, routine blood investigations including complete blood count and coagulation profile were done and the patient was haemodynamically stable.
Treatment
The patient was asked to gargle with a 10% povidone-iodine solution as a routine disinfection protocol. The 2% lidocaine with 1:200 000 epinephrine was injected locally around the lesion at the apex of the tongue. Adjacent tissues were coated with petroleum jelly for protection against collateral tissue damage. Cryosurgery was performed using nitrous oxide gas delivered using a cryoprobe (figure 2). The procedure was carried out in a single session of two cycles of 1 min each, with a 2-minute interval between cycles. Immediately after the procedure, the lesion appeared whitish, denoting freezing, followed by oedema and erythema formations denoting the thawing process. The patient was observed for a period of half an hour after which she was discharged.
Intraoperative picture showing the freezing cycle of the lesion at the right corner of mouth using a cryoprobe.
Outcome and follow-up
On the second week of review, the lesion at the tip of the tongue completely regressed and the patient was planned for the treatment of remaining lesions using the similar protocol employed earlier. Similar freeze–thaw cycles were used in two sessions for all other lesions at 2-week intervals. Complete regression was observed of all lesions. No recurrence was observed during the 12-month follow-up period (figure 3). No signs of infection, sensory changes, scar or skin discolouration were noted during the healing period and at follow-ups.
Postoperative image after 12 months showing the complete resolution of all the lesions with minimal damage to adjacent tissue.
Discussion
Oral haemangiomas are relatively common lesions of the oral cavity and are either cavernous or capillary type, depending on the vascular pattern. Haemangiomas are painless and vary from a millimetre to several centimetres in diameter, and occur most frequently on the tongue, lip vermilion or buccal mucosa. Oral haemangiomas are red or blue, reflecting the venous character of the blood and their deep mucosal position.8 9 The clinical significance of oral haemangiomas depends on the degree of invasion of the underlying structures, frequency of traumatic episodes, ulceration, bleeding, scarring and their ability for continued growth. Large haemangiomas may be involved with the associated anatomical structures that surgical management of such lesions is usually contraindicated. Lack of encapsulation significantly prevents their complete eradication. Most recorded haemangiomas (85%) occur in the first year of life. Congenital haemangiomas usually recede on their own. Those that do not spontaneously regress or that occur in older individuals are treated with surgery, radiation therapy, sclerosing agents injected into the lesion, cryotherapy or compression.10 11
Cryotherapy is controlled and targeted destruction of diseased tissue by the application of cold substances.7 12 Two methods of cryotherapy are: an open system that uses direct application of liquid nitrogen (−196°C) as a spray or using a cotton tip over the lesion and a closed system using probes and gases such as nitrous oxide (−89°C), carbon dioxide (−78°C) and freons (fluorinated hydrocarbons with low boiling point).13 Closed systems offer a greater degree of control and accuracy compared with open systems but with more sophisticated hardware.14 Therefore, a closed system using cryoprobe and nitrous oxide was selected in our treatment protocol. The pattern of cell death following freezing is by direct or indirect effect. Intracellular and extracellular crystallisation occurs as a first step. However, secondary or vascular effects are caused by increased vascular permeability and capillary liquid extravasation to outside of the cell leading to cell death. It is also believed that immunological effects are effective because this process can stimulate the immune system.15 Next, freezing can be a fast or slow cycle. Intracellular ice formation and severe damage to the protein membrane are seen in the fast-freezing cycle and are more dangerous than in slow cycles. During thawing, cells at the edges of the frozen lesion will absorb more electrolytes. To balance this gradient, water enters the cell and can lead to inflammation and lysis. This explains thawing, as well as freezing, are important determinants of cell destruction.13 Slow thawing is associated with the recrystallisation of ice and is much more dangerous than rapid thawing.16 Cells near the tip of the probe are at a greater risk of injury compared with the surrounding cells, which are at a much lower risk of injury due to the proximity of the probe.17 Freezing should be repeated twice for each area to ensure an adequate effect. The ice ball should extend slightly beyond the edges of the wound so that about three-quarters of the observed diameter of the frozen tissue is at the lethal cell temperature of 15°C for normal tissue. Sloughing of the central tissue usually occurs about one week after and may be expected to heal within 3–6 weeks. The lethal effect of thawing suggests that repeated cycles of freezing and thawing are potentially more destructive than single long-time freezing.18 Cryotherapy using a closed system has very few side effects including unpredictable rate of swelling, uncontrolled depth and area of freezing and high operator dependency.19
The management of vascular lesions requires a staged approach. The treatment should be individualised for every patient based on the location of the lesion, the type of lesion and the aesthetic concern of the patient. Cryotherapy offers a promising solution in treating haemangiomas in sensitive areas by reducing the postoperative complications.
Patient’s perspective
Ever since my daughter was diagnosed with this problem, we lived our lives on the edge because the physician had said that if the lesion ruptures it might become life threatening. She had lot of difficulty pronouncing words and consuming food. She was ridiculed by her classmates for the presence of these swellings, and she even skipped schools on most of the days to avoid being bullied.
Another worry that we had was the aftereffects of surgery. I was worried if there will be a defect post-surgery and she will have to live with that throughout her life. I was a bit sceptical at first when the doctors suggested me cryotherapy. I was worried if the lesions will recur. But thankfully the treatment phase was very comfortable for my daughter and even after a year the lesions haven’t recurred. Now my daughter can interact with people comfortably and her focus on studies has also improved.
Learning points
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This is a classic presentation of haemangiomas post-infancy.
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Prompt investigation, appropriate diagnosis and proper treatment method are crucial in managing this lesion.
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Cryotherapy is effective, less invasive, easy to perform and offers promising results in the treatment of haemangiomas.
Ethics statements
Patient consent for publication
Acknowledgments
The authors would like to thank the Department of Obstetrics and Gynecology for providing us with the cryoprobe for the procedure. The authors would also like to acknowledge Dr Kalpa Pandya and Dr Abitha Venkatesan for their help during patient care.
Footnotes
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Contributors PS, GGVV, PA and BKVKR were involved in patient care. PS, PA and BKVKR were involved in the drafting of the manuscript. PS and GGVV were involved in the approval of the final draft.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.
References
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