The radiotherapeutic management of subglottic hemangioma in children.

Abstract

From 1946 to 1964, a total of 28 cases of subglottic liemangioma causing airway obstruction in children have been referred for radiation therapy to the Department of Radiology at the Children's Hospital Medical Center, Boston, Mass. In a review of the available literature, only 24 additional cases from other Centers could be readily found (1, 3, 4, 6–12, 14–16). This confirms the general impression of most writers that subglottic hemangioma is an unusual entity in the pediatric age group. Most laryngeal hemangiomas are found in the adult. Of the 125 cases collected by Ferguson (6), 117 occurred in adults and 8 in children. Sweetser (16) was the first to recognize that the lesion in the adult is an entity distinct from that in the child in regard to site, symptomatology, and clinical appearance. In the adult, the lesion is cordal with a characteristic reddish-blue color. It may be pedunculated or have a broad base, imparting a “raspberry-like” appearance (16), and it is sharply demarcated from surrounding tissues. Because of its location, hoarseness is the most prominent symptom, with dyspnea of relatively less importance. Other symptoms are those of cough, hemoptysis, and dysphagia (6). The less common lesion in the child is typically immediately below the cords in the subglottis, with a color less definite and possibly obscured by the overlying mucosa. It is sessile and less well demarcated from surrounding structures (1, 5). Because of its subglottic position, the lesion is clinically manifest by symptoms of upper respiratory tract obstruction (16). Slight infection, with increased narrowing of the airway due to inflammation and edema, may exacerbate the symptoms which are nonspecific and vary in severity. Dyspnea and inspiratory stridor are the earliest and most common symptoms (6). Croupy cough and markedly labored respirations are frequently noted. In some patients, symptoms are progressive, while in others there are periods of intermittent remissions. Signs of acute infection are not too prominent. A few cases have shown the more marked signs of retraction and cyanosis. Although hoarseness is unusual in the child, it occurred in one of our patients; here the subglottic lesion extended superiorly to involve the true cords. Poor feeding and a failure to gain weight are more likely to be associated with a chronic process and are perhaps due to the recurrent respiratory distress. Many patients have associated hemangiomas of the skin (6). In a review of the literature, one-half the reported 24 cases from other Centers demonstrated such an association (5), and this same percentage was observed in our series. Thus, although not an absolute sign, the presence of a visible hemangioma in an infant with respiratory difficulty is suggestive of the same lesion involving the airway. In 27 of our patients symptoms appeared by three months of life and were diagnosed by the age of six months. The oldest patient at diagnosis was eighteen months of age, with symptoms not appearing until approximately the age of twelve months.