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What is Infantile Subglottic Hemangioma? • Infantile subglottic hemangioma is a benign vascular tumor that arises in the subglottic region of the airway. It is a type of infantile hemangioma, the most common vascular tumor in infancy, but its subglottic location makes it potentially life-threatening due to the risk of airway obstruction. • Clinical Presentation • The clinical course typically follows a predictable pattern: • • Age of Onset: Subglottic hemangiomas usually present around 4 to 6 weeks of age, coinciding with the proliferative phase of the hemangioma. • Stridor: The most common symptom is progressive inspiratory stridor, which often worsens with crying, feeding, or supine positioning. This stridor may initially mimic laryngomalacia but becomes more concerning as the airway obstruction progresses. • Respiratory Distress: In severe cases, infants may present with signs of respiratory distress, such as retractions, tachypnea, and cyanosis. It is important to distinguish this from other causes of stridor like croup or subglottic stenosis. • Biphasic Stridor: In cases where the hemangioma is large and nearly obstructing, a biphasic stridor may be observed due to both inspiratory and expiratory obstruction. • Diagnosis • Diagnosis is established through a combination of clinical assessment and imaging: • • Flexible Laryngoscopy: This is the first-line tool, allowing direct visualization of a bluish or purplish mass in the subglottic area. This confirms the presence of a vascular lesion. • Direct Laryngoscopy and Bronchoscopy (DLB): DLB is the gold standard for both diagnosis and assessment of the degree of airway obstruction. It helps in determining the exact location, size, and extent of the hemangioma. • Imaging: If the diagnosis remains uncertain or further anatomical details are needed, MRI or CT imaging can be used. MRI is particularly useful for assessing soft tissue involvement and any potential extralaryngeal extension. • Step-by-Step Management • Management depends on the severity of symptoms and the degree of airway obstruction: • 1. Observation: In cases with mild symptoms and minimal obstruction, close monitoring might be appropriate, as many hemangiomas enter an involution phase around 12-18 months of age. However, this is only suitable for stable patients without significant stridor or respiratory distress. • 2. Medical Therapy: • Propranolol: This non-selective beta-blocker is the first-line treatment for symptomatic subglottic hemangiomas. The typical starting dose is 1-2 mg/kg/day, divided into two or three doses. It is crucial to monitor heart rate, blood pressure, and blood glucose levels during initiation. • Propranolol works by vasoconstriction, decreasing angiogenesis, and inducing apoptosis of the endothelial cells. It often leads to a rapid reduction in the size of the hemangioma, with improvement in symptoms within days to weeks. • Systemic Corticosteroids: Prednisolone can be used as an adjunct or alternative when beta-blockers are contraindicated. It is usually given at a dose of 2-4 mg/kg/day, tapering over several weeks as symptoms improve. • 3. Airway Management: • For severe cases where the infant presents with significant obstruction and distress, airway stabilization is the priority. • Intubation may be necessary to secure the airway while medical therapy is initiated. This should be done with caution due to the risk of further trauma to the subglottic region. • In cases of severe airway compromise not responsive to medical therapy, tracheostomy may be required as a life-saving measure. It provides a secure airway and allows time for the hemangioma to involute with propranolol therapy. • 4. Surgical Interventions: • If medical management fails to achieve adequate symptom control, surgical options are considered. • Laser excision using CO2 laser can be used to remove part of the hemangioma, but it carries risks of scarring and subglottic stenosis. • Open surgery like laryngotracheal reconstruction (LTR) may be considered in cases where there is significant airway compromise that has not responded to other measures. • 5. Follow-Up and Monitoring: • Regular follow-up with flexible laryngoscopy is essential to monitor the response to therapy and ensure that the airway remains patent as the hemangioma involutes. • It is important to continue propranolol therapy for at least 6-12 months to reduce the risk of rebound growth when treatment is tapered off. • Prognosis • With the advent of propranolol therapy, the management of infantile subglottic hemangioma has shifted from primarily surgical to medical, with many infants achieving resolution of symptoms and avoiding invasive procedures. Early recognition and initiation of treatment are key to preventing complications and ensuring optimal outcomes. • #ear #nose #throathealth

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