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.