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Original Investigation |

Propranolol Therapy for Reducing the Number of Nasal Infantile Hemangioma Invasive Procedures

Jonathan A. Perkins, DO1,2,3; Brian S. Chen, MD4; Babette Saltzman, PhD1; Scott C. Manning, MD2,3; Sanjay R. Parikh, MD2,3
[+] Author Affiliations
1Seattle Children’s Hospital Research Institute, Seattle, Washington
2Division of Pediatric Otolaryngology–Head and Neck Surgery, Department of Surgery, Seattle Children’s Hospital, Seattle, Washington
3Department of Otolaryngology–Head and Neck Surgery, University of Washington School of Medicine, Seattle
4Department of Otolaryngology–Head and Neck Surgery, Madigan Healthcare System, Tacoma, Washington
JAMA Otolaryngol Head Neck Surg. 2014;140(3):220-227. doi:10.1001/jamaoto.2013.6524.
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Published online

Importance  Propranolol therapy is changing the treatment paradigm for infantile hemangioma. This study addresses the effect of propranolol therapy on the treatment of nasal infantile hemangioma (NIH), an area that often does not respond to medical therapy.

Objective  To determine if propranolol treatment is associated with fewer invasive treatments for NIH.

Design, Setting, and Participants  Retrospective cohort study conducted within a single pediatric institution’s multidisciplinary vascular anomaly program for patients with NIH treated between January 1, 2003, and December 31, 2011. Three NIH cohorts were compared: prepropranolol (20 in group 1; 2003-2009), propranolol (25 in group 2; 2009-2011), and nonpropranolol (13 in group 3; 2009-2011) treatment.

Interventions  Analysis of systemic medical, laser, or surgical therapies for NIH.

Main Outcomes and Measures  The study plan was created to detect a change in invasive therapy for NIH. Data collected included presenting age, sex, affected nasal subunits, infantile hemangioma morphologic characteristics, treatment type and number, and primary treating service. An NIH grading system, based on nasal subunit involvement, helped quantify treatment change. Descriptive statistics summarized data, and a Cox proportional hazards regression model evaluated propranolol use and the likelihood of invasive treatments (surgical excision or laser).

Results  Of the 95 patients identified, 58 met inclusion criteria: 20 in group 1 (mean age, 4.8 months), 25 in group 2 (mean age, 4.9 months), and 13 in group 3 (mean age, 4.9 months). Nasal infantile hemangiomas involved the nasal tip subunit in 33 of 58 patients (56.9%). Eight of 13 patients (61.5%) in group 3 frequently had small NIH (grade 1). Patients in group 2 were less likely to undergo any invasive treatments (relative risk, 0.44; 95% CI, 0.27-0.73), have surgical excision only (0.45; 0.15-1.38), or undergo laser treatment only (0.44; 0.27-0.78) compared with those in group 1. Patients with higher-grade NIH had more medical or invasive therapy, but invasive procedures were carried out in each subgroup defined by grade.

Conclusions and Relevance  Patients with isolated propranolol-treated NIH were less likely to undergo invasive treatment, but despite its implementation, the need for invasive treatment was not totally supplanted by its use.

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Figures

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Figure 1.
Nasal Infantile Hemangioma Grade

A, Grade 1: superficial soft tissue triangle and columella infantile hemangioma (IH). B, Grade 2: superficial and subcutaneous nasal tip IH, involving 1 nasal subunit. C, Grade 3: superficial and subcutaneous nasal IH, involving 2 subunits (nasal dorsum and left nasal side wall). D, Grade 4: superficial and subcutaneous nasal IH, involving 3 or more subunits (nasal tip, dorsum, and bilateral nasal side walls) and nasal obstruction.

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Figure 2.
Partial Regression of Grade 1 Nasal Infantile Hemangioma

A, Grade 1 lesion (superficial right nasal side wall) treated with 2 mg/kg/d of propranolol for 2 months with tumor shrinkage and decreased erythema. B, The progress halted, so the parents opted for surgical excision. C, Four months after the operation, it is still a clinical grade 1 lesion.

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Figure 3.
Significant Regression of Grade 4 Nasal Infantile Hemangioma

A, Grade 4 lesion (mixed tip, superficial dorsum, side wall, and ala) treated with 2 mg/kg/d of propranolol for 4 months (B) and 10 months, with resolution of the deep components, but the superficial component remains, making it a clinical grade 1 lesion. Pulsed-dye laser may be warranted in the future to decrease the superficial erythema and thickness. C, After 8 months of propranolol treatment, at 14 months postpropranolol treatment. No laser treatment performed.

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Figure 4.
Partial Regression of Grade 4 Nasal Infantile Hemangioma

A, Grade 4 lesion (mixed tip, dorsum, and bilateral nasal side walls). B, Treatment with 2 mg/kg/d of propranolol for 10 months. There was residual fibrofatty tissue, so surgical excision was offered. C, Four months after the operation.

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Figure 5.
Near-Complete Regression of Grade 3 Nasal Infantile Hemangioma

A, Grade 3 lesion (mixed tip and columella) treated with 2 mg/kg/d of propranolol for 24 months. B and C, Now a grade 2 lesion isolated to the nasal tip with minimal residual deep irregularities seen on anteroposterior and basal views.

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Figure 6.
Nasal Infantile Hemangioma in Group 1 Not Treated With Propranolol

A, Grade 3 lesion involving subcutaneous and superficial nasal dorsum and side wall treated with 2 laser treatments followed by 2 surgical excisions. B, Postoperatively, this is a grade 1 lesion (residual erythema). C, Grade 4 lesion with subcutaneous and superficial involvement of the nasal dorsum, both sidewalls and soft tissue triangles, tip, and columella. This was treated with 3 laser treatments initially, followed by 2 surgical excisions, resulting in a grade 1 lesion. D, Six months following the second nasal surgery. Note red mark is a small unrelated abrasion.

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