DOI: 10.1097/01.prs.0000175951.02431.4f
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PMID: 16079718
Issn Print: 0032-1052
Publication Date: 2005/08/01
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Excerpt
We are troubled by the recommendations of Reinisch and colleagues in their article entitled “Surgical Management of Parotid Hemangioma.”1 They describe 17 patients who underwent resection of parotid hemangioma, of whom 13 (77 percent) were 2 years of age or younger. They rationalized early resection by referencing a small series of patients with parotid hemangioma who reportedly had failed pharmacological treatment.2 Another reason given for timely removal was to limit potential psychosocial problems.
The authors’ premise that drug therapy is ineffective for hemangioma involving the parotid is erroneous. Reinisch et al. seem dismissive of medical treatment: only three of their 17 patients received systemic corticosteroid, while the others had no drug treatment (n = 7), intralesional corticosteroid (n = 6), or laser photocoagulation (n = 1). Five months earlier in this Journal, we analyzed our experience in managing 100 children with parotid hemangioma and determined that pharmacologic treatment is just as effective as in other locations.3 In our series, 83 percent of parotid hemangiomas regressed or stabilized on systemic corticosteroid, and 95 percent of tumors responded to interferon. We are also surprised that Reinisch et al. used intralesional corticosteroid injections for parotid hemangioma rather than the systemic route. Multiple injections around, and possibly in, the facial nerve can cause axonal injury.
The need for operations is not disputed: two-thirds of our patients required some type of resection for contour, preauricular scarring, or cutaneous laxity. However, we disagree with the timing of resection proposed by Reinisch and his colleagues. Only three of 17 patients in their series had resection of fibrofatty residuum after completion of involution, and none of them required exposure of the facial nerve. All 13 patients who had early resection had a more extensive parotid procedure, including dissection of the facial nerve in five patients. Postoperative problems included hematoma (n = 2), transient facial nerve palsy (n = 2), and need for blood transfusion (n = 1). Other authors have documented major blood loss, injury to the facial nerve, and even death after resection of parotid hemangioma.4,5
In summary, we are concerned that surgeons who lack the experience and technical skill of Dr. Reinisch might embark on an operative misadventure. Many parotid hemangiomas can be observed; they will undergo predictable natural regression, often resulting in normal contour, especially deep tumors.3 Treatment with systemic corticosteroid is indicated for problematic proliferating phase tumors (i.e., those that expand the cheek skin, cause ulceration, or are associated with congestive heart failure or respiratory compromise). If there is no response to corticosteroid, consider interferon or vincristine. Finally, we recommend postponing operations until the child is 3 to 5 years old or older, since during the involuting phase the tumor is smaller, fibrofatty, and less vascular, and rarely is dissection of the facial nerve needed. The potential risks of early resection of parotid hemangioma far outweigh the arguable psychological benefits.
