Vocal Fold Hemangioma

A 37-year-old male physician complaining of hoarseness for 3 years, presented to our ENT polyclinic when he realized that he had had occasional hemoptysis for the last three months. He had been smoking ½ pack of cigarettes every day for 5 years. He had no history of alcohol use, trauma, intubation, voice abuse, reflux symptoms or any other systematic diseases. On flexible nasopharyngolaryngoscopy, there was no pathologic finding that could explain the origin of hemoptysis except for a vegetative tumor mass located on anterior one-third of his right vocal fold. The vocal folds were mobile, and there was no airway obstruction.The patient underwent microlaryngeal surgery under general anesthesia. Surgery revealed a pink – reddish, granular and hypertrophic mass connected with a wide stalk on the free edge of the right vocal fold (Figure 1A). There was no extension to the anterior commissure, arytenoids or subglottic area. The lesion was excised completely (Figure 1B). As more bleeding occurred than expected, an intravenous bolus dose of 1 g of tranexamic acid was administered to the patient and cotton balls soaked with tranexamic acid were applied to the site of excision. The postoperative course was uneventful, and the patient experienced no further symptoms. Histopathological examination of the specimen revealed capillary hemangioma of the vocal fold with thin-walled, dilated vascular structures, predominantly capillaries and endothelial linings, in the subepithelial areas (Figure 2).

Figure 1.

(A) Hemorrhagic polypoid mass on the free edge of the right vocal fold, (B) Postoperative microscopic view.

Figure 2.

(H&E, x40) Please note dilated capillaries in the submucosal area.

Discussion

Hemangiomas are benign vascular tumors commonly seen in the head and neck region. Laryngeal hemangiomas are divided into infantile and adult forms. Infantile hemangiomas are more frequent than adult ones, and they are commonly subglottic. In adults, the occurrence of laryngeal hemangiomas is quite rare, and supraglottic involvement is the most common site for such cases. ¹ There are only a few cases reported in the literature that have originated from the free edge of the true vocal folds. ^{1 –5} These cases were cavernous hemangiomas histopathologically except one. That case also was reported as a capillary hemangioma on the free edge of the right vocal fold. ³ Hoarseness was the main symptom in all patients, and hemoptysis was infrequent. ⁴ We used tranexamic acid-soaked cotton balls locally on the vocal folds and also as in intravenous form to control brisk, pulsatile bleeding. The use of tranexamic acid in the management of hemangiomas is discussed in the literature, and it has been suggested that it helps stop bleeding with topical treatment of pediatric hemangiomas, and facilitates rapid healing on crusted and eroded areas of such lesions which have already started to involute. ⁶

The treatment options for airway hemangiomas vary according to the age of the patient, as well as the localization, size and hemodynamic pattern of the lesion. In adults, smaller hemangiomas can be managed conservatively. Systemic and intralesional steroids, interferon, laser ablation, surgical excision, cryosurgery, radiation therapy and even temporary tracheotomy can be performed in larger hemangiomas. ^1,2,4 As vocal fold hemangiomas are very rare, they can be misdiagnosed easily as simple polyps or warts. Such lesions must be examined thoroughly before preparing the patient for biopsy or surgical excision.