DISCUSSION
ALHs that appeared to be bluish-red were commonly observed at or above the true cords7. Adult hemangiomas can be located on the laryngeal ventricle, the false vocal cords, the epiglottis, the arytenoids, the laryngeal vestibule, the aryepiglottic fold, or the pyriform sinus. Hemangiomas may be found in one or more locations, which makes the lesions more complicated. Active treatment is advised if the lesions are symptomatic or if they are growing. There is a risk of hemangiomas rupturing, which may induce serious bleeding and can result in death, as food may go through the arytenoids. Therefore, ALHs located on the arytenoids should be treated.
The optimal surgical approach to treat ALHs is still debated. Chemotherapy is an effective and safe method to treat haemangiomas8. In our study, 0.3 million units/mL bleomycin was used. Bleomycin can affect the G2 and S phases of fast-dividing cells and can induce DNA degradation in undercoiled chromatin regions9,10. The ALH excision surgery can be performed using many methods, such as using cold instruments, a holmium laser, and a CO2 laser. Some authors consider that excision is not advisable for adult cavernous hemangiomas in view of the great diameter of vascular spaces and the significant diameter of vessels1. However, Steiner and Ambrosch2 state that laryngeal cavernous hemangiomas can be successfully removed if they are pedunculated or limited to circumscribed areas.
In the retrospective study, we collected the data of ALH in the ALH excision group and chemotherapy group. We compared the baseline characteristics of ALH including: locations, classification, ALH size and demographic characteristics of the patients in two groups. No statistically significant between-group differences for either of the primary outcomes were detected. The indifference of ALH data meant the ALH in chemotherapy group might also surgically excisable. This might avoid bias in surgical selection.
Our study showed that all the patients in the ALH excision group were cured and experienced no recurrence. The curative effect in the ALH excision group was better than in the chemotherapy group. In addition, side effects such as tumor ruptures and hemorrhoea did not occur. Why did the ALH excision surgery have better results? First, ALH excision was used only when the ALH was located on arytenoids that were circumscribed. Second, the histological characteristic of arytenoids make ALHs located there different from ALHs located elsewhere, as the soft tissue of the arytenoids is loose. Furthermore, the CO2 and holmium lasers can excise the base of hemangiomas if the laryngeal forceps clip the hemangiomas and the surrounding loose, soft tissue. Last, the bases of ALHs located on the arytenoids can be exposed more easily. The basal plane of ALHs located on the arytenoids can be parallel to the line of sight if the laryngeal forceps clip the lesions.
In our study, one patient treated with a bleomycin injection had a poor therapeutic result. The lesion was then excised using a CO2 laser and a holmium laser. The CO2laser was applied after the volume of the ALH was reduced by siphoning off blood from the ALH using a 23-gauge needle.
ALH excision is a better method to treat ALHs located on the arytenoids. However, there is still a risk of the hemangioma rupturing and a risk of hemorrhoea. Before this surgery, it must be determined whether the bases of the lesions are limited located on the arytenoids by the laryngoscope and contrast-enhanced CT. Exploration before lesion resection is also necessary. If lesions cannot be completely removed during preoperative evaluation, alternative procedures must be used. It is important to have experienced doctors for successful surgery.
Numerous modalities in the treatment and management of hemangiomas have been proposed, including Nd:YAG laser excision11,12, CO2 laser excision13, potassium-titanyl-phosphate (KTP) lasers14, electrocautery, cryotherapy15, sclerotherapy, interferon alfa-2a16, corticosteroids, embolization, and radiation therapy17,18. These methods can mainly be divided into excision methods and non-excision methods. For ALHs located on the arytenoids, the excision method produces better results. However, preoperative evaluation of the base of ALHs and surgical experience are critical.