The rare adult vocal cord hemangioma: A case report

Abstract

Laryngeal hemangiomas are benign tumors and are categorized into two types—infantile and adult. Adult-type vocal cord hemangiomas are very rare and uncommon in clinical practice. A 71-year-old man came to medical attention because of blood-tinged sputum and hoarseness for 1-month duration. Endoscopic examination revealed a well-demarcated vegetative lesion attached to the right vocal cord. The lesion was superficially located, and therefore amenable to complete surgical excision. Post-operation followed up showed improved symptoms and without evidence of local recurrence. Based on the histopathological features, a diagnosis of cavernous hemangioma of the vocal cord was rendered. Currently, there is no clear and unequivocal treatment and management modality in adult-type hemangioma, we reported a case with adult-type laryngeal hemangioma using cold instrument microlaryngoscopic excision technique with satisfied result.

Keywords:

• Hoarseness
• hemangioma
• cavernous hemangioma
• vocal cord

Introduction

Vascular anomalies have been classified into two major groups according to International Society for the Study of Vascular Anomalies (ISSVA) system, vascular tumor and vascular malformations. While vascular malformations are not true neoplasms but are localized defects of vascular morphogenesis caused by dysfunction in embryogenesis and vasculogenesis, vascular tumors are characterized by endothelial cell hyperproliferation, typically grow rapidly, and most are not present at birth [1]. Laryngeal hemangiomas are benign vascular tumors of endothelial origin, which commonly being categorized into two types—infantile and adult. The infantile-type is more common, more frequent in girls and mostly founded in the subglottic area [2]. The adult-type is rare, more common in males and usually at supraglottic area. From the point of histology, laryngeal hemangiomas formed mainly by cavernous, capillary, or mixed type [3]. The adult form of laryngeal hemangioma is rare, with only 36 cases reported in the English-language literature since 1979 [1,2,4–17].

Case report

A 71-year-old man visited our outpatient department (OPD) complaining of blood-tinged sputum, which he had been experiencing for 1 month since contracting an upper respiratory tract infection. He also complained of hoarseness. The patient did not have a history of drinking or smoking.

In the OPD, flexible endoscopy was performed, which revealed a vegetative tumor located at the anterior third of the right vocal cord (Figure 1). The vocal cords were able to move freely, and no airway obstruction was observed. Laryngeal hemangioma was impressed and surgical intervention under microscope was recommended and arranged.

Figure 1. Fiberoptic laryngoscopic image of a right vocal cord hemangioma.

During the operation, the patient was placed in the Boyce–Jackson position for the optimal exposure of the vocal cords. The tumor was inspected under a microscope, gently grasped with forceps, and excised from the base with micro-scissors. The excision site was then compressed with an adrenaline-soaked cotton ball for hemostasis. Blood loss was less than expected preoperatively. Histopathological examinations of the specimen revealed the proliferation of crowding and dilated vessels with marked congestion and focal inflammation, confirming the diagnosis of cavernous hemangioma of the vocal cords, size (0.9 cm × 0.7 cm × 0.5 cm) (Figure 2).

Figure 2. Histopathological image of a vocal cord cavernous hemangioma revealing the proliferation of crowding and dilated vessels with marked congestion and focal inflammation. (H&E, × 100).

One week after the operation, the wound appeared healing well (Figure 3) and the patient denied hemoptysis or coughing out blood-tinged sputum. He also stated the improvement of his voice. Unfortunately, the patient missed the scheduled follow-up (5 weeks after the operation) and was lost to follow-up again.

Figure 3. Fiberoptic laryngoscopic image of the vocal cords 1 week postoperatively.

Discussion

Benign lesions constitute 5% of all laryngeal masses, with papilloma being the most common type. Other types of laryngeal masses include chondroma, hemangioma, lymphangioma, schwannoma, neurofibroma, adenoma, granular cell myoblastoma, leiomyoma, rhabdomyoma, fibroma, lipoma, and paraganglioma [18]. Laryngeal hemangiomas are slowly progressing vascular tumors, which are commonly diagnosed in children but rarer in adults. Because of their rarity, the exact incidence and etiology of the tumor remain unclear [2,19].

The symptoms of adult-type laryngeal hemangioma are different from those of the infantile-type, which are more obvious, and present difficulty in breathing, stridor, and the appearance of skin lesions. The main symptoms of adult-type hemangioma include hoarseness, dyspnea, dysphagia, and pharyngeal foreign body sensation [2,5].

In our case, the patient experienced only hoarseness and occasional blood-tinged sputum in the absence of other symptoms. To confirm a diagnosis of hemangioma, thorough evaluation by laryngoscope and pathological examination are mandated because some cases might be confused with hemorrhagic vocal cord polyps, because of its blood-filled translucent appearance.

Hemangiomas can be classified into three types histopathologically according to the vessel size and wall thickness: capillary, cavernous, and mixed types. Cavernous hemangioma, the type presented in this case report, is the most common [3,10,13,19]. The treatment for adult-type laryngeal hemangioma has no clinical guideline, partly because of its rarity, size, and clinical symptoms differ in each case. For small and asymptomatic laryngeal hemangiomas, some literatures stated that close observation had been considered to be sufficient [1,2,6,9,17]. However, large hemangiomas with symptoms require interventions to prevent ulceration, infection of vital organs, and upper airway obstruction. We believe in cases with symptomatic laryngeal hemangiomas, even small in size should receive surgical intervention as early as possible because laryngeal hemangioma do not regress spontaneously as infantile-type do and some authors advocate early intervention when the lesions are still restrict to the most superficial submucosa [19].

Clinical and surgical treatment methods reported in the literature, including surgical resection, corticosteroid injections, ethanol injections, cryosurgery, radiation therapy, and laser surgery [1,6,8,12,19,20]. In our case, we use micro-scissors for removing the mass resulting in minimal scaring to the vocal fold. We suggest that small hemangiomas using cold instrument can reduce thermal injury to peripheral tissue, offset the inherent danger of potentially catastrophic airway and well preserved of the patient’s voice.

Conclusion

This report adds to the current cases by suggesting that excision of the small adult- type laryngeal hemangioma using cold instruments maybe acceptable and a safe way without using expensive or cumbersome equipment.

Ethical approval

Informed consent was obtained from the patient of this case report, and the study protocol was approved by the Ethics Committee of Kaohsiung Medical university (the IRB number was KMUHIRB-E(I)-20220059).

Disclosure statement

No potential conflict of interest was reported by the author(s).