Case report
Initial experience using propranolol as the sole treatment for infantile airway hemangiomas

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Abstract

The objective of this study is to describe the initial use of propranolol as the sole treatment for focal infantile airway hemangiomas, and to report on available literature describing the use of propranolol for airway lesions. This retrospective case series was carried out at a tertiary pediatric medical center. We obtained the following results: two children demonstrated significant response to oral propranolol therapy and avoided not only invasive surgical procedures, but also long-term administration of oral corticosteroids. This is the first report of treating infantile airway hemangiomas with only propranolol without additional surgical intervention or corticosteroid use. Review of literature reveals initial case series with similar, successful results using propranolol as an adjuvant treatment along with other medications and surgical interventions. We conclude that the initial use of propranolol as the sole treatment for infantile airway hemangioma is promising. Literature review reveals that propranolol as the sole treatment for most head and neck hemangiomas shows significant promise based on early case reports. Further studies are needed to determine the long-term effectiveness, dosing strategies, and side effect profile of propranolol treatment for hemangiomas.

Introduction

Infantile hemangiomas are the most common pediatric tumor occurring in approximately 1–2% of newborns, with a much higher rate in premature infants [1]. The natural course has been well documented with most becoming apparent within the first 2 months of life, undergoing a proliferative phase in the first year of life, and slowly involuting over the early childhood years. Frequently infantile hemangiomas involve the head and neck region and have a significant cosmetic component. More serious lesions involving the airway and orbit necessitate early intervention to avoid airway compromise and vision abnormalities.

Medical treatment of infantile airway hemangiomas has centered upon intralesional and oral steroids with interferon and vincristine being reserved for life threatening lesions [2]. Surgical treatment has included tracheotomy, laser excision, and open airway excision [3]. None of these treatments are without significant side effects. Long-term corticosteroid administration can result in growth suppression and other developmental and metabolic derangements. Furthermore, steroid treatment alone will result in the need for a tracheotomy in over one-third of patients [2]. Infant tracheotomy has a well documented morbidity rate, laser excisions pose a significant risk for airway scarring, and open airway procedures require experienced surgeons with highly skilled intensivist post operative care [4], [5], [6].

Propranolol has recently been introduced as a treatment for infantile hemangiomas [7], [8], [9], [10], [11]. Initial case reports have demonstrated rapid response to oral propranolol in both skin and airway hemangiomas after primary medical and surgical treatment were unsuccessful [7], [8], [9], [10], [11]. No report though has specifically identified using propranolol as the initial and only treatment for airway hemangioma. In this paper we describe infantile hemangiomas involving the supraglottic and subglottic airway that were all treated solely with propranolol.

Section snippets

Case 1

A 3-month old, otherwise healthy infant female, presented with gradual onset of inspiratory stridor over a 2-week period. There were no feeding difficulties and no apneic or cyanotic episodes. Skin exam did not reveal any lesions and head and neck exam was normal except for a flexible nasopharyngoscopy which revealed a supraglottic mass suspicious for a hemangioma. Imaging to include an MRI of the neck revealed an isolated paraglottic mass consistent with a hemangioma. Ultrasound of the brain

Literature review

Propranolol treatment for infantile hemangiomas has only recently been described [7], [8], [9], [10], [11]. Initial success was found fortuitously when a nasal hemangioma was noticed to decrease in size after propranolol treatment was started for obstructive cardiomyopathy [7]. Since this time there have been case reports describing successful treatment of infantile hemangiomas with propranolol as an adjuvant medication after other medical and surgical treatments have failed; successful

Conclusion

There is a growing literature base that demonstrates the effectiveness of propranolol as a treatment for head and neck infantile hemangiomas. Initial success along with a low side effect profile is an exciting breakthrough for the treatment especially of infantile airway hemangiomas where many children suffer the untoward side effects of corticosteroids and the complications inherent in tracheotomy and multiple laser procedures. Airway hemangiomas are relatively rare so long-term prospective

Conflict of interest statement

Authors report no financial conflicts of interest relative to this article. There was no external funding associated with this report.

References (11)

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