Transoral Robotic Surgery and Transarterial Embolization to Treat Adult Laryngeal Hemangioma

Significance Statement

Laryngeal and hypopharyngeal hemangiomas are benign tumors that occur in the head and neck region and are rare in adults. In this case, surgical resection using transoral robotic surgery (TORS) was performed, followed by postoperative transarterial embolization (TAE). TORS is an effective treatment for oral tumors, and TAE is a vital adjunct for managing these tumors. TORS combined with TAE represents a feasible approach to treating hemangiomas in adults.

Clinical Report

For several months, a 31-year-old man felt he had a lump in his throat. Magnetic resonance imaging was conducted and revealed a suspected hemangioma over the right supraglottic region. Nasopharyngoscopy was conducted, and a vessel-abundant reddish-purple mass was clearly observable above the right-side false vocal fold and ventricle, extending to the right aryepiglottic fold and occupying nearly hemi larynx from the anterior to posterior commissure of the vocal fold (Figure 1). Although not entirely obstructing the airway, the tumor continued to grow in the following months, thus necessitating active intervention. We first used angiography to attempt to identify and block the major vessels feeding the tumor, but examination revealed no obvious enhancement around the tumor. We then performed a tracheotomy, followed by TORS (Figure 2), during which profuse bleeding complicated the surgical field. After hemostasis was achieved, TAE was immediately performed; slight focal-contrast extravasation was noted over the right supraglottic region and blocked. No life-threatening complications occurred during and following the procedures. However, 3 months later, the tumor had grown larger despite initial obvious shrinkage. We thus adopted the same method of treatment as employed in the first round of treatment, namely a tracheotomy and TORS, followed by TAE; in TAE, the right superior thyroid artery was successfully obliterated by using embosphere microspheres (Figure 3). After undergoing intensive care and proper assessment in the postoperative period, the patient was discharged in a stable condition. Since then, he has returned for weekly follow-up, with the tumor remaining unchanged in size and appearance. No critical complications have occurred.

Figure 1.

Vessel-abundant reddish-purple mass clearly observable above the false vocal fold.

Figure 2.

Transoral robotic surgery for radical treatment of adult laryngeal hemangioma.

Figure 3.

Transarterial embolization used to successfully obliterate the right superior thyroid artery by using embosphere microspheres.

Hemangiomas are benign tumors comprised of blood vessel clusters and commonly found in neonates, whose incidence is 2.5%. ¹ By contrast, hemangiomas are rare in adults. They appear as well-defined bluish-red masses, are often located deep within the glottis and supraglottis, and grow slowly.^2,3 In men, hoarseness is the main symptom, with hemoptysis, dysphagia, and breathing difficulties occurring in more advanced cases. ³

At present, no consensus or guidelines have been established regarding the optimal treatment of head and neck hemangiomas in adults. Asymptomatic cases are typically managed through clinical observation as long as the tumors remain stable and do not threaten the surrounding structures. ³ However, if symptoms worsen or the tumor invades nearby regions, prompt action is necessary to prevent life-threatening complications.

Various treatment modalities are available for laryngeal or hypopharyngeal hemangiomas, with surgery being the primary approach. Other methods include laser therapy, cryosurgery, sclerotherapy, radiation therapy, and corticosteroid injections. ³ TAE has emerged as a valuable adjunct to surgical treatment and is sometimes the sole option for patients at high risk of complications. ⁴

Surgical excision through microlaryngoscopy or laser ablation is suitable for small tumors. For larger tumors, preventive tracheotomy is considered. Laser cauterization, however, may be ineffective in extended cases because it increases the risk of mucosal damage and postoperative subglottic stenosis. ³ TORS is effective in treating oral tumors because it is precise, features 3D vision, and is implementable in small spaces; it generally results in a safe and successful resection. ² This minimally invasive approach minimizes the amount of normal tissue removed, controls bleeding, and reduces blood loss, leading to quicker recovery. ³

TAE has emerged as a valuable tool for the surgical treatment of hemangiomas. Preoperative embolization of head and neck hemangiomas has been proven to be safe and enhance the likelihood of complete removal during surgery. This technique minimizes blood loss, reducing surgical morbidity and mortality. Moreover, when performed immediately after surgical excision, TAE enhances the extravasation of contrast medium, enabling more accurate blockage of feeder vessels, and decreasing the risks of damage to adjacent normal tissue and tumor recurrence. ⁴

In the case presented herein, we performed a preventive tracheotomy during both surgeries to mitigate the risk of airway obstruction. Surgical resection was performed using TORS, and in collaboration with the radiology department, postoperative percutaneous tumor embolization was arranged. The patient has been monitored since treatment, with no significant complications or recurrent symptoms. Nasopharyngoscopic examinations have revealed no tumor recurrence. This case report demonstrates that combining TORS and TAE offers a promising approach to managing laryngeal and hypopharyngeal hemangiomas in adults.