RECENT ADVANCES IN OTORHINOLARYNGOLOGY

8/7/2019 RECENT ADVANCES IN OTORHINOLARYNGOLOGY

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RECENT ADVANCES IN

OTORHINOLARYNGOLOGY

SCLEROTHERAPY


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DEFINITION

Sclerotherapy is defined as the targeted

elimination of small vessels, varicose veins

and vascular malformations by the injectionof a sclerosant into the lumen of the vessel.

The aim of sclerotherapy is to damage the

vessel wall and transform it into a fibrous

cord that cannot be recanalized.


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MECHANISMOFSCLEROTHERAPY

The various sclerosants used cause a marked

damage to the endothelium of the vessels

and, possibly, of the entire vascular wall.Subsequently, a secondary, local thrombus

attached to the vessel wall is generated and

the vessel is finally transformed into a fibrous

cord, i.e. sclerosis.


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Table 1: Indications for sclerotherapy


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Vascularmalformations Vascular malformations are currently classified as arterial, capillary, venous, lymphatic and combined.

True hemangiomas often involute with age, while vascular malformations remain stable or slowly growwith the patient, and typically require some form of therapy when cosmetic disfigurement, bleeding orfunctional impairment occur.

From a therapeutic perspective, one of the most important differentiating characteristics of vascularmalformations is their classification as "high flow" or "low flow" based on findings at physical examination,

imaging or both.

Sclerotherapy is indicated in the treatment of low-flow vascular malformations and symptomatichemangiomas. High-flow vascular lesions do not respond to sclerotherapy alone and require surgicalintervention.

However, in high-flow lesions, sclerotherapy may be utilized prior to surgery to decrease the size of thevessels and reduce the intraoperative bleeding.

In case of hemangiomas, the current treatment strategy is that any proliferative lesion that carries a risk ofulceration or bleeding or that is rapidly expanding in a cosmetically sensitive area is a candidate for earlyintervention. Sclerotherapy is indicated for the treatment of large rapidly proliferating or ulceratinghemangiomas.


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Whytouse sclerotherapy forvascular

malformations Small lesionscan be treated by either excision or

sclerotherapy or laser therapy. But lasers canonly be applied for the treatment of superficial

lesions in oral mucosa For the voluminous and extensivelesions,

complete surgical excision is seldom achieved.BecauseVMs grow among soft tissues, such as

muscles, nerves and bloodvessels, they aredifficult to delineate during surgery.

For these reasons, there is increasing interest insclerotherapy in treatment ofVM


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MethodoftreatmentThe lesion to be treated and the surrounding skin are cleaned with

an antiseptic solution

A small needle (usually a 24 or 25 gauge) is inserted into the tumorand the sclerosing solution injected, the needle is kept moving

through the tumor.

The sclerosing agent is kept away from the surface to avoidulceration.

Upon completion of the injection, firm pressure is made over the

lesion for five minutes.

When repeated treatments are required, the interval between

treatments is usually one to three weeks, depending upon thetissue reaction.

Hemangiomas that have most of their bulk beneath the skin

surface and are thus not amenable to freezing with solid

carbondioxide are chosen for injection with sclerosingA

gents.


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Table 2: Sclerosing agents


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Detergent Solutions

Include sodium morrhuate, Ethanolamine

oleate, STS, and polidocanol.

These agents act specifically on venousendothelium. They induce sclerosis bydamaging the endothelium via interference

with cell membrane lipids.


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Sodium tetradecyl sulphate

Very effective in the treatment of difficulthemangiomas not amenable to surgery

Dose:0.05 to 0.1 cc at multiple sites in total dosesnot exceeding 2.0 to 4.0 cc.

SIDE EFFECTS: The most common seriousadverse effect with STS is anaphylaxis.

STS can cause a burning sensation pain forseveral minutes after injection


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SODIUM MORRHUATE

Sodium morrhuate is a sodium salt of a fatty

acid extracted from cod liver oil.

Not destructive to tissues and therefore leastlikely to produce tissue necrosis

The dose of it is 1 to 5cc of the 5 %. solution,

the average dose being 2cc.


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Polidocanol

Dose:2-3cc of 1% solution Compared with STS, polidocanol causes less

vessel spasm and more erythema, resulting in

increased bleeding after needle withdrawal One to three injections was usually sufficient to

obtain the sclerosis effect.

Urtication is more prevalent with polidocanol

than with other agents. Post sclerotherapyhyperpigmentation occurs following polidocanoladministration in 10%30% of patients and canlast over one year.


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Osmotic agents

Exert their effects by dehydrating endothelial

cells through osmosis,which results in

endothelial destruction. Because osmotic agents are rapidly diluted in

the bloodstream, they lose their potency

within a short distance of injection and are

less effective in the treatment of veins largerthan 3 to 4mm in diameter.


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Hypertonicsalinesolution

Low cost, ready availability, lack of allergenicity ofunadulterated solutions, and rapid clinical effect

The significant adverse effects of hypertonic saline relate toits non-specific action of destroying cells within its osmotic

gradient. Therefore extravascular injection is liable to causecutaneous ulceration, which can also occur withintravascular injection via diffusion through a damagedendothelium.

Diffusion of hypertonic saline through the vein wall also

results in irritation of adventitial nerves, causingpostinjection pain and transient muscle cramping.

Concentration:Suggested hypertonic saline concentrationsare 23.4% for reticular veins (2-4 mm) and venulectasias (1-2 mm) and 11.7% (half strength) for telangiectasias (


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Absoluteethanol Its presumed mechanism of action is a direct toxic effect on the

vascular endothelium that activates the coagulation system on thedehydrated endothelium. Thus, the vascular occlusion is notachieved instantly but rather in days to weeks.

The toxic effect extends to the perivascular tissue, and the use ofabsolute ethanol has led to perivascular necrosis.

It is among the most popular of agents used in oral vascularmalformations today; it is delivered permucosally, percutaneously,

or through catheters. Ethyl alcohol (95%), which is percutaneously injected into the

lesion, is similar to absolute ethanol.

Dose:A total volume of 1ml/kg is safe. When using absoluteethanol, approximately one third of the volume of the lesion canbe injected.


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BLEOMYCIN

Bleomycin is an established antineoplastic drug, butrecently successful attempts were made to inject itlocally as a sclerosing agent in cases of congenitallymphatic malformations cystic hygromas andhaemangiomas,in the treatment of recurrentintractable epistaxis in patientswith HHT.

Local complications encountered were superficialulceration,cellulitis,systemic complications were flu-like symptoms,transient hair loss.

For the treatment of low-flow venous and lymphaticmalformations in adults the maximal total dose ofbleomycin injectedper treatment session should notexceed 15 U .


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OK-432

OK-432 (Picibanil) is a lyophilized incubation mixture ofgroupA Streptococcus Pyogenes of human origin.

It has lost its streptolysin producing ability but retained theabilities that produce local inflammatory mediators.

OK-432 immunotherapy is an effective, safe, and simpletreatment option for the management of macrocysticcervicofacial lymphatic malformations.

DOSE:0.2 mg per injection delivered at eight-weekintervals

The complications of OK- 432 include partial trachealobstruction, local oedema, fever, local inflammatoryresponse and rarely abscess formation.


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FOAM SCLEROTHERAPY

Mixing a detergent sclerosing agent with a gas(commonly air) results in foam formation.

Foam is obtained after repeated alternate passages

from one syringe to another through a connector. Compared to traditional liquid sclerotherapy, foam

sclerotherapy has certain advantages including asmaller volume of the sclerosing agent needed forinjection, lack of dilution with blood (dilution

decreases efficacy), homogeneous effect along theinjected veins, and ultrasound echogenicity.

The use of foam sclerotherapy is generally reservedfor larger vessels and not spider veins.8


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LIMITATION

Sclerotherapy is not effective for the

treatment of flat portwine stains, high-flow

lesions likeAV

fistulas.


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ABSOLUTE CONTRAINDICATION

Advanced peripheral arterial occlusive

disease

Hyperthyroidism (in the case of sclerosantscontaining iodine).

Pregnancy in the first trimester and after the

36 th week of gestation.

Known allergy to the sclerosant.

Severe systemic disease.


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RELATIVE CONTRAINDICATION

Long-standing diabetes.

Poor general health.

Myocardial decompensation. Migraine.

Bronchial asthma.

Marked allergic diathesis. Known hypercoagulability.


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RECENT ADVANCES IN OTORHINOLARYNGOLOGY

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