Hemangiomas - Complications

Some serious complications may accompany hemangiomas. The most common complication
is ulceration, which is caused when the skin can no longer accommodate
the growth of the hemangioma causing it to split open. Infection is common
once an ulcer has developed, particularly on the lip, the perianal, and
genital areas. A topical antibiotic may be applied to the ulcer although
long-term use of topical antibiotics always poses a risk of developing
an allergy to the antibiotic. Bacitracin and Polysporin however pose less
risk of hypersensitivity with long-term use.

Two of the most serious problems associated with nasal hemangiomas are destruction
of cartilage of (either on the nostril or the nasal septum), and displacement
of the cartilage that forms the nasal tip. As the hemangioma grows
in this area, it pushes the cartilages apart from the nasal tip so that
when the hemangioma finally shrinks, the nose is disfigured. We therefore
believe its best to excise the nasal tip hemangioma sooner rather than
later. This will enable us to reappose the cartilages and allow normal
growth of the nose.

A certain type of hemangioma, usually a particular pattern of distribution
involving the lower third of the face, that stretches from in front of
one ear to the chin and then to the other side of the face, is also commonly
associated with airway obstruction. This type of hemangioma obstructs
the airway at the level of the pharynx sometime during the first six months
of life. A child with pharyngeal airway obstruction will have symptoms
of noisy breathing during inhalation. Aggressive intervention with steroids
(to shrink the lesion) is the first line of treatment. If the obstruction
isn't relieved, a tracheostomy will be necessary.

A hemangioma of the larynx may also obstruct the child's airway. This is
a life-threatening situation and urgent aggressive intervention is necessary.
This hemangioma may be above or below the vocal cords, or involve the
vocal cords themselves. This type of hemangioma will usually obstruct
the airway far quicker than a pharyngeal hemangioma will. The hemangioma
actually begins to grow inside the airway and obstructs breathing. The
child develops a croupy, barking cough with noisy breathing on both inhalation
and exhalation. Our first line of treatment is steroids (see advances
in treatment). Most laryngeal hemangiomas that don't respond to aggressive
steroid treatment require a tracheostomy so the child can breathe. If
the hemangioma is diagnosed early enough, aggressive steroid treatment
may prevent the need for tracheostomy. Lasers are also useful if the hemangioma
is isolated and accessible. There are complications associated with lasers.
This procedure should therefore be done by an experienced surgeon.

The most common cause of blindness in the developed world is deprivation amblyopia,
which is caused by the blocking of a child's visual field during the final
stages of the development of the retina. Hemangiomas that obstruct the
visual field during this period can cause blindness and should be promptly
treated. Hemangiomas can also cause astigmatism by virtue of their bulk
and pressure on the cornea.

Therefore if an hemangioma is likely to obstruct the visual axis, this constitutes
an emergency. The hemangioma can be treated with a course of steroids
to reduce its size and relieve the obstruction to the child's vision.
If steroid treatment fails, both interferon and surgical removal need
to be considered.

Some hemangiomas cause a life threatening condition known as Kassabach-Merritt
syndrome. In this condition, the hemangioma destroys the blood platelets
which in turn can result in a fatal bleeding disorder. Any very large
hemangioma should be suspect for Kassabach-Merritt syndrome and blood
platelet levels should be checked if a child has an aggressive, large
hemangioma prior to six months of age. The treatment of this syndrome
should be managed by a hematologist or a physician experienced in treating
this condition. The child needs to be hospitalized and carefully monitored
until he/she is stable. Steroids are usually started with the maximum
dose given for up to four weeks and then tapered very slowly over 2-to-3
months. The blood platelet level as well as various other indicators are
monitored during this time and the steroid dose can be manipulated as
needed. Interferon may also be used and if the lesion responds to interferon,
the physician may want to try and discontinue the steroids and just use
the interferon. Since interferon has the potential to cause permanent
spasticity, it should be used with caution. However in a life-threatening
situation, the benefits of interferon treatment outweigh the risks.

Hemangiomas may rarely cause Disseminated Intravascular Coagulation (DIC). With this
extremely rare bleeding disorder, the blood platelets and other clotting
factors are used up by a large blood clot in the growing hemangioma. This
blood clot grows until, eventually, all the platelets and other clotting
factors are depleted. Heparin is given to try and stop the clot from growing,
but it doesn't always work. Because DIC is such a catastrophic condition,
death often results.This condition is extremely rare.

Some hemangiomas on the head and neck area, especially very large lesions,
or multiple systemic hemangiomas on the liver and intestines can cause
High Output Cardiac Failure. This problem can occur anytime during proliferation
or early involution. The early symptom of failure can appear as an infant
that fails to eat well and does not gain weight (failure to thrive). Alternatively,
the child will have a rapid pulse rate and an enlarged heart. The child
will also be susceptible to chest infections.

This heart failure is the result of the hemangioma causing the heart to work
harder to pump blood. Over time, the heart enlarges so it can pump more
efficiently. The heart is a muscle, and it can only enlarge to a certain
point. When that point is reached, it can't compensate or continue to
function efficiently. If the heart doesn't pump the blood out fast enough,
the blood starts backing up into the lungs. Fluid also collects in the
lungs, so these children are especially susceptible to chest infections.
Without treatment, 40 to 50 percent ofTreatment entails eliminating the
cardiac failure with drugs or surgically removing
the hemangioma. Before any surgical intervention is tried, aggressive
steroid treatment should be tried. Only a surgeon skilled in removing
lesions should perform this type of surgery. these children die.