Sage Journals: Discover world-class research

Abstract

Importance

Adult laryngeal hemangiomas are rare and may cause symptoms such as dysphonia, dysphagia, and dyspnea. Carbon dioxide (CO2) lasers offer an alternative approach to managing this rare condition.

Objective

The objective of this study is to evaluate the effectiveness of CO2 lasers in treating adult hemangioma and to identify potential side effects associated with this treatment modality.

Design/Methods

The study utilizes the PRISMA model to systematically collect articles available in the current literature. The numbers obtained from each academic manuscript were then used to calculate the effectiveness of CO2 laser therapy in patients with laryngeal hemangiomas. Articles from 1949 to 2023 were gathered using the PRISMA systematic review method.

Setting

Not applicable

Participants

Adult patients with laryngeal hemangioma who were treated with CO2 lasers.

Intervention or Exposures

Surgical management with CO2 lasers.

Main Outcome Measures

Number of patients with at least a 50% reduction in laryngeal hemangioma size.

Results

Two case reports, 4 case series, and 2 observational studies were included in this systematic review. For the case reports and series, only 1 out of the 19 patients experienced recurrence following CO2 laser treatment. However, some studies did not have adequate follow-up time. In the 2 observational studies, efficacy rates of 100% and 90.9% were reported by the authors respectively.

Conclusion and Relevance

Adult laryngeal hemangioma can be safely and successfully treated with CO2 laser microsurgery in well-selected cases. More studies, as well as longer patient follow-ups, are needed to truly assess the efficacy of CO2 laser in treating laryngeal hemangioma. This method provides a minimally invasive technique for adult patients with this rare disease.

Graphical abstract

Keywords

adult laryngeal hemangioma carbon dioxide laser hemangioma microsurgery

Introduction

Hemangiomas consist of blood vessels that form benign vascular tumors.^1,2 These tumors represent the most prevalent type of benign tumors seen at birth.³ Although close to 60% of hemangiomas are detected in the head and neck area, it is uncommon for them to present in the larynx.^1,4 Laryngeal hemangiomas occur more frequently in pediatric patients, with an incidence of around 4% to 5%, where they are often benign and spontaneously regresses during toddler years.^5,6 However, laryngeal hemangiomas are even rarer in adults, and their exact incidence is unknown due to the rare nature of the disease.⁷ Unlike the infantile variant, adult laryngeal hemangiomas typically do not regress on their own and they typically present in the supraglottic region.⁸ Adult patients who experience laryngeal hemangiomas may experience symptoms of dysphonia, dysphagia, shortness of breath, and hemorrhages.^2,9

Some of the common treatment modalities for adult laryngeal hemangioma include laser resection, cryosurgery, corticosteroid injections, and cold steel surgery.¹⁰ Carbon dioxide (CO2) laser microsurgery has been widely used in otolaryngology and is an alternate technique to traditional cold steel procedures.^11,12 This type of laser operates by using CO2 gas as a medium to produce precisely focused light energy at 10,600 nm wavelength, which can easily slice, coagulate, and vaporize water-rich soft tissue.^12,13

The CO2 laser has been extensively used, having been the primary laser used to surgically excise laryngeal masses.^14,15 With flexible laryngoscopy, otolaryngologists have begun using CO2 laser during office-based procedures under local anesthesia.¹⁵ Complications with the CO2 laser are rare but have been reported to include infection, postoperative bleeding, dyspnea, and dysphagia. However, most patients respond without problems and experience immediate relief following therapy.¹⁶ In this systematic review, we hope to address the following question: is surgery with CO2 laser efficacious for adult patients with laryngeal hemangioma? The primary outcome to determine the success of the CO2 laser is a 50% or greater reduction in size of the hemangioma, as well as the recurrence rate.

Review of the Literature

Methods

Study Design

PRISMA review model was employed to collect articles for this study.¹⁷ The PubMed and EMBASE databases were searched for articles on “laryngeal hemangioma” using PRISMA guidelines. PubMed yielded 745 articles (1949-2023) and EMBASE 521 articles (1974-2023). Inclusion criteria focused on the use of lasers in treating laryngeal hemangioma, while exclusions included non-CO2 lasers, patients under 18, and non-English articles. Figure 1 outlines these criteria.

Figure 1.

Study flow chart.¹⁷

Study Selection

The 5-stage screening process began by evaluating article titles for relevance. Relevant titles were then screened for their abstracts, and those with pertinent information were assessed in full. These stages are shown in Figure 1. Ultimately, reviewers extracted data from 8 relevant articles for the systematic review. Table 1 summarizes the titles, year, type of CO2 laser, outcomes, and keynotes for the case reports and series included in this study. Table 2 summarizes the results of the 2 observational studies included in this systematic review.

Table 1.

CO2 Lasers in Adult Patients with Laryngeal Hemangioma for Case Reports and Case Series.

Authors	Power of laser	Mode	Age	Gender	Presenting symptoms	Smoking history	Diagnostic tools	Location	Description	Follow up time	Recurrence	Complications	Type of hemangioma	Tracheostomy	Other
Alshaya et al¹⁸	5 W	Continuous	30	F	4-year history of dysphonia, voice fatigability, and thin fluid aspiration	No	Flexible fiberoptic nasolaryngoscopy and MRI.	Right supraglottic	An irregular bluish lesion measuring 3 × 2.2 × 2.5 cm in the craniocaudal, transverse, and anteroposterior dimensions.	24 months	No	None	N/A	N/A	Steady improvement in vocal function.
Kulkarni et al⁸	10 W	Continuous, superpulsed, and scanning beam	42	M	1 year of dysphagia and hoarseness	N/A	Contrast-enhanced CT and MRI	The laryngeal side of the epiglottis, left aryepiglottic fold, left arytenoid region, left true and false vocal cords, and the medial portion of the left pyriform sinus.	A bluish, smooth mass with poorly defined borders and heterogeneous hypodensity, measuring 27 × 16 × 22 mm.	12 months	No, but minimal lesion on laryngeal surface of epiglottis and left arytepiglottic fold	None	N/A	Yes, 24 weeks	The patient received an initial CO2 laser treatment, with two additional procedures carried out over a span of 20 weeks. Asymptomatic following surgery.
Laohakittikul and Srirompotong¹⁹	8 W	Continuous	47	M	7-year history of hoarseness and globus sensation.	10 pack years	Fiberoptic laryngoscopy	Left anterior half of vocal cord	A pinkish-red mass on the left vocal fold, obstructing the anterior and middle portions of the vocal cord, measuring 1.5 cm.	4 months	No	None	Cavernous hemangioma	N/A	Normal voice
			55	M	3-month history of hoarseness with little hemoptysis.	No	Fiberoptic laryngoscopy	Anterior edge of left vocal fold	On the left vocal fold, a large, red, pedunculated mass is obstructing the anterior half of the laryngeal lumen, measuring 1.5 cm.	3 months	No	None	Cavernous hemangioma	N/A	Vocal function improved to near normal performance.
			45	M	3-month history of hoarseness and 7-day history of minimal hemoptysis	12 pack years	Fiberoptic laryngoscopy	Left vocal fold	A large, smooth, reddish pedunculated mass on the left vocal fold, measuring 1.3 cm.	1 month, lost to follow up	No	None	Cavernous hemangioma	N/A	Voice improvement
			56	M	5-month history of hoarseness.	No	Fiberoptic laryngoscopy	Anterior edge of right true vocal fold	A 0.5 cm smooth, pink mass is present at the anterior edge of the right vocal fold.	1 month	No	None	Cavernous hemangioma	N/A	Normal voice
			58	F	2-month history of hoarseness.	No	Fiberoptic laryngoscopy	The anterior half of the left true vocal fold	Left vocal fold: A 0.5 cm pink, pedunculated mass located in the anterior half of the vocal fold.	4 months	No	None	Capillary	N/A	Normal voice
Lomeo et al²⁰	10 W	Continuous	35	F	1-month history of dyspnea	30 pack years	Fiberoptic laryngoscopy and biopsy	Right vocal fold	Large, pink hemangioma obstructing the airway	18 months	No	None	N/A	N/A	No difficulty breathing, even when lying flat. Voice returned to normal.
			64	F	Several year histories of dysphonia and dyspnea	80 pack years	Videostroboscopy and Biopsy	Right vocal fold	Blue mass, no involvement of deep structures	18 months	No	None	N/A	N/A	Voice improvement
			38	M	Hoarseness	30 pack years	Laryngoscopy and biopsy	Right anterior commissure	N/A	N/A	No	None	N/A	N/A	N/A
			34	F	Hoarseness	10 pack years	Laryngoscopy and biopsy	Left true vocal fold	N/A	12 months	No	None	N/A	N/A	Voice returned to normal
Lucioni et al²¹		Superpulsed	42	M	Hemoptysis	N/A	Videolaryngoscopy	Supraglottis	N/A	40 months	No	None	N/A	No	N/A
			40	M	Dyspnea	N/A	Videolaryngoscopy + MRI	Supraglottis	N/A	30 months	No	Significant intraoperative bleeding	N/A	Yes for 5 days	N/A
			49	M	Hemoptysis	N/A	Videolaryngoscopy	Supraglottis	N/A	16 months	No	None	N/A	No	N/A
			50	M	Dysphonia	N/A	Videolaryngoscopy	Supraglottis	N/A	26 months	No	None	N/A	No	N/A
			28	M	None	N/A	Videolaryngoscopy	Supraglottis	N/A	40 months	No	Intraoperative bleeding	N/A	N/A	N/A
			27	M	Dysphagia and snoring	N/A	Videolaryngoscopy + MRI	Supraglottis/Hypopharynx	N/A	24 months	Yes	First Treatment: Major intraoperative hemorrhage and lasting unilateral vocal fold paralysis.Second Treatment: No issues.	N/A	N/A	The lesion remained in the retro-cricoid and arytenoids after 20 months. Treatment involved staged CO2 laser excision: the first stage targeted the supraglottic hemangioma, and the second stage, 8 months later, addressed the pyriform sinus hemangioma. A 24-month follow-up showed only minimal persistence in the retro-cricoid and arytenoid areas.
Mesolella et al²²	8-10W	Superpulsed	61	M	2 month history of hoarseness	10 cigarettes per day for 20 years	Laryngoscopy	Right vocal cord	Extensive blue-purple mass	24 months	No	None	Cavernous Hemangioma	N/A	Significant improvement in voice with normal vocal cord movement observed.
			30	M	4 month history of hoarseness	10 cigarettes per day	Indirect laryngoscopy	Left vocal cord	Bluish-black color ed mass	36 months	No	None	Endocordal cyst and capillary hemangioma	N/A	Significant improvement in voice with normal vocal cord movement observed.

Table 2.

CO2 Lasers in Adult Patients with Laryngeal Hemangioma for Observational Studies.

Authors	Power of Laser	Mode	Treatment	Total patients treated with CO2 laser	Number of patients with good response to CO2 laser	Efficacy rate	Keen findings	Other	Hemangioma characteristics	Presenting symptoms
Fang et al²³	2 W	Pulsed	CO2 laser excision group	3	3	100%	All 3 patients with CO2 excision experienced complete remission. The authors did not report recurrence rates, although most patients did not have follow-ups exceeding 6 months.	3 patients had lesions to their larynx. No major postoperative complications were reported.	Non-bulky size and exophytic type	N/A
Wu et al²⁴	6 W	Pulsed	CO2 laser (6 W) + Chemotherapy	11	10	90.90%	The mean lumen constriction score for this group was 3.18. The authors did not report recurrence rates.	One patient was lost to follow-up in the CO2 group, and the observed efficacy rate was 90.9%. No major adverse effects were reported.	N/A	N/A

Quality Assessment and Data Abstraction

The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports was used to assess the quality and risk of bias for the 2 case reports included in this review.²⁵ There were 8 criteria for this assessment tool, where scores between 7 and 8 were considered good quality, 4 to 6 were considered fair quality, and 0 to 5 were considered poor quality (Table 3). The two reviewers (K.D. and E.K.) independently examined whether each study fulfilled the criteria outlined by the study quality assessment tool. A senior investigator (J.L.B.) supervised this review process and intervened if there were discrepancies in evaluations.²⁵

Table 3.

Risk of Bias Assessment of Case Reports.

Criteria	Alshaya et al¹⁸	Kulkarni et al⁸
Q1: Were patient’s demographic characteristics clearly described?	N	Y
Q2: Was the patient’s history clearly described and presented as a timeline?	Y	Y
Q3: Was the current clinical condition of the patient on presentation clearly described?	Y	Y
Q4: Were diagnostic tests or assessment methods and the results clearly described?	Y	Y
Q5: Was the intervention(s) or treatment procedure(s) clearly described?	Y	Y
Q6: Was the post-intervention clinical condition clearly described?	Y	Y
Q7: Were adverse events (harms) or unanticipated events identified and described?	N	N
Q8: Does the case report provide takeaway lessons?	Y	Y
Final quality score	6	7
Rating	Fair	Good

The Joanna Briggs Institute Critical Appraisal Checklist for Case Reports.

The National Institute of Health (NIH) recommended tool was implemented in this systematic review to assess the quality and risk of bias for the 4 case series and 2 observational studies included in this review (Tables 4 and 5).²⁶ In accordance with this tool, case series were evaluated based on 9 questions, where scores 7-9 were considered good quality, 5 to 6 were considered fair quality, and 0 to 4 were considered poor quality. Observational studies were evaluated based on 14 questions, where scores between 11 and 14 were considered good quality, 7 to 10 were considered fair quality, and 0 to 6 were considered poor quality.²⁶

Table 4.

Risk of Bias Assessment of Case Series.

Criteria	Laohakittikul and Srirompotong¹⁹	Lomeo et al²⁰	Lucioni et al²¹	Mesolella et al²²
Q1: Was the study question or objective clearly stated?	N	Y	Y	N
Q2: Was the study population clearly and fully described, including a case definition?	Y	Y	Y	Y
Q3: Were the cases consecutive?	Y	Y	Y	Y
Q4: Were the subjects comparable?	Y	N	Y	Y
Q5: Was the intervention clearly described?	Y	Y	Y	Y
Q6: Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?	Y	Y	Y	Y
Q7: Was the length of follow-up adequate?	Y	Y	Y	Y
Q8: Were the statistical methods well-described?	N	N	N	N
Q9: Were the results well-described?	Y	Y	Y	Y
Final Quality Score	7	7	8	7
Rating	Good	Good	Good	Good

Quality Assessment Tool for Clinical Case Series (https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools).

Table 5.

Risk of Bias Assessment for Observational Studies.

Criteria	Fang et al²³	Wu et al²⁴
Q1: Was the research question or objective in this paper clearly stated?	Y	Y
Q2: Was the study population clearly specified and defined?	Y	Y
Q3: Was the participation rate of eligible persons at least 50%?	Y	Y
Q4: Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?	Y	Y
Q5: Was a sample size justification, power description, or variance and effect estimates provided?	N	N
Q6: For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?	Y	Y
Q7: Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?	Y	Y
Q8: For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)?	Y	N
Q9: Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?	Y	Y
Q10: Was the exposure(s) assessed more than once over time?	Y	N
Q11: Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?	Y	Y
Q12: Were the outcome assessors blinded to the exposure status of participants?	N	N
Q13: Was loss to follow-up after baseline 20% or less?	Y	Y
Q14: Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?	N	N
Final Quality Score	11	9
Rating	Good	Fair

Quality Assessment Tool for Observational Studies (https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools).

Definitions

The lumen constriction score was referenced by Wu et al to assess the therapeutic outcomes of patients who had undergone different treatment options, including CO2 laser combined with pingyangmycin injection.²⁴ According to Wu et al, this is a 4-point scale, where the numeric scale employed for evaluation had distinct interpretations: “1” denoted absence of size change, “2” represented a 50% reduction in lesion size, “3” indicated a reduction between 51% and 100%, while “4” signified a complete cure, with the lesion disappearing and not recurring for at least 1 year.²⁴

Results

Study Quality

The quality and risk of bias for studies included in this systematic review were evaluated based on criteria outlined by the Joanna Briggs Institute Appraisal Checklist for Case Reports and the National Institutes of Health study quality assessment tool. After evaluation, it was determined that 6 of the studies included in this study were considered good quality and 2 were considered fair quality.^25,26

Case Reports and Series Patient Characteristics

Two case reports^8,18 and four case series^19-22 were aggregated for this systematic review. A total of 19 patients were included across these 6 studies, which consisted of 14 male and 5 female patients. The average age of these patients was 43.7 years old with a standard deviation of 11.5 years. The presenting symptoms of the 19 patients included 13 (68.4%) with hoarseness or dysphonia, 4 (21.1%) with hemoptysis, and 3 (15.8%) with dyspnea. Additionally, 2 (10.5%) presented with dysphagia, while 1 (5.3%) each had voice fatigability, thin fluid aspiration, globus sensation, or snoring. One patient (5.3%) had no presenting symptoms. Some patients presented with more than one symptom.

Among the studies that explicitly reported patients’ smoking status, 8 out of 12 patients had a significant smoking history. The number of cigarettes smoked or the pack years is detailed in Table 1.

The supraglottic region was the most common site for hemangiomas, with 7 out of 19 patients (36.8%) having lesions in this area. Among these patients, one individual (5.3%) had additional involvement in the hypopharynx. The left vocal fold was affected in 6 out of 19 patients (31.6%), while 4 out of 19 patients (21.1%) had lesions on the right vocal fold. Additionally, one patient (5.3%) had widespread involvement including the laryngeal surface of the epiglottis, left aryepiglottic fold, left arytenoid, left true/false cords, and left medial wall of the pyriform sinus. Another patient (5.3%) had involvement at the right anterior commissure.

Patient follow-up time also varied across case reports^8,18 and series^19-22. Seven patients (36.8%) had a follow-up time of a year or less, six patients (31.6%) had a follow-up time of between 1 and 2 years, five patients (26.3%) had a follow-up time of more than 2 years, and 1 patient (5.3%) had an unknown follow-up time. Out of these 19 patients, only Lucioni et al reported recurrence of the disease in 1 patient.²¹ Although Kulkarni et al. did not report a recurrence of the hemangioma, a small residual lesion was present on the epiglottis and aryepiglottic fold because complete removal was not feasible.⁸

Across the 19 patients, complications were only noted by Lucioni et al, who reported 3 cases of significant intraoperative bleeding.²¹ The authors did not quantify the bleeding. Furthermore, the authors reported 1 case of permanent unilateral vocal cord paresis at 24-month follow-up.²¹

Case Reports

Alshaya et al presented a 30-year-old female patient who underwent continuous CO2 laser excision at 5 Watts (W).¹⁸ The lesion was excised successfully, and the patient’s vocal functions improved. The patient was regularly checked for 2 years, and there was no recurrence of the hemangioma. She did not experience any adverse effects from the procedure.¹⁸

Kulkarni et al reported a 42-year-old male patient who initially was given a polidocanol injection.⁸ However, the mass did not respond to the treatment, where a continuous CO2 laser at 10 W was performed 20 days later. The patient underwent two more episodes of laser therapy over the course of 5 months. Twelve months later, a follow-up examination revealed that while the mass was not entirely removed due to a conservative approach, the patient continued to show no symptoms, and there were no significant obstructions of the airway.⁸

Case Series

Laohakittikul and Srirompotong followed 5 patients with ages ranging from 45 to 58 years old.¹⁹ Four male and one female patients were diagnosed with laryngeal hemangiomas, each presenting with hoarseness and distinct locations within the larynx. In all cases, the patients underwent excision using an 8-watt CO2 laser therapy, resulting in normal vocal cord function, absence of bleeding, unobstructed airway, and no tumor recurrence.¹⁹

Four patients were treated with CO2 in the case series by Lomeo et al.²⁰ The patients were a 35-year-old women, a 64-year-old women, a 34-year-old men, and a 38-year-old men. All patients had a significant smoking history, with the pack years ranging from 10 to 80. All of the patients underwent a CO2 laser excision of their laryngeal hemangiomas at 10 W under the continuous mode. Their lesions responded completely to the therapies. No recurrence and no significant complications were observed following the procedures.²⁰

Lucioni et al examined 6 male patients who presented with laryngeal hemangioma.²¹ Their median age was 41.0 years. They were treated with a super-pulsed CO2 laser at 1 to 8 W. Following the procedures, 5 out of the 6 patients experienced no recurrence at a median follow-up time of 29 months. It is important to note that 3 patients experienced blood loss during the operation, and 1 experienced permanent unilateral vocal fold paralysis.²¹

The case series by Mesolella et al examined a 61-year-old male patient and a 30-year-old male patient who presented with hemangioma to their right and left vocal cords respectively.²² At 8 weeks, both patients’ voices improved significantly. In both patients, no serious complications occurred and there was no recurrence of the hemangioma.²²

Observational Studies

Two studies by Fang et al²³ and Wu et al²⁴ were observational studies and did not detail the demographics specifically for the subgroup of patients who had laryngeal hemangioma and underwent CO2 therapy, as these studies also included other treatment options and patients with hypopharyngeal involvement. Fang et al examined 68 patients who presented with laryngeal or hypopharyngeal hemangioma.²³ Depending on the size and morphology of the lesions, patients were treated with CO2 laser excision, CO2 laser coagulation + bleomycin injection, or potassium-titanyl-phosphate (KTP) laser + bleomycin injection. For our systematic review, we only assessed the efficacy of the CO2 lasers in patients with laryngeal hemangioma. There were 3 patients in the group who solely received CO2 laser excision. The power of the CO2 laser used in the excision group was 2 W. The authors in this study found that all 3 patients in the CO2 laser excision group experienced complete remission of the hemangiomas, defined as the total absence of the lesion on the laryngoscopic view. The mean follow-up time of CO2 laser patients, which included both laryngeal and hypopharyngeal patients, was 9.9 months. The study did not report any major postoperative complications for the treated patients.²³ It is important to note that Fang et al also studied one group with CO2 laser coagulation + bleomycin injection, and there were 10 laryngeal and 10 hypopharyngeal patients with an average age of 47.5 years old. However, although 9 patients had complete remission, 9 had partial remission, and 2 had stable disease, we were not able to differentiate the responses to CO2 laser between the laryngeal and hypopharyngeal hemangioma patients.²³ As a result, the patients in the CO2 laser coagulation + bleomycin injection were not included in the quantitative synthesis of this systematic review.

The retrospective observational study by Wu et al²⁴ reviewed 38 patients with an average age of 47.7 years who had undergone 48 procedures, including conventional chemotherapy, potassium-titanyl-phosphate (KTP) laser, and CO2 laser combined with chemotherapy.²⁴ The number of cases for the CO2 laser group combined with pingyangmycin was 12, although 1 patient was lost to follow-up. A continuous CO2 laser approach at 6 W was used on these patients, and the study found a 90.9% efficacy rate for the patients who were in this group. The mean lumen constriction score was 3.18. The authors reported no major adverse effects following the operations.²⁴

Discussion

The precise etiology of adult laryngeal hemangiomas remains uncertain, though potential contributors include vocal cord injury, intubation, trauma, and smoking.² In our case report and case series section, the smoking status of 12 patients was revealed, where 8 of them had an extensive smoking history. Smoking likely contributes to chronic inflammation, irritation, and cellular damage to the larynx, leading to the development of laryngeal hemangioma.²⁷

The most common presenting symptoms reported by patients in this systematic review were hoarseness or dysphonia. Generally, the primary goal is to completely remove the lesion during surgery.²⁸ However, due to the complex anatomy and the risk of functional impairment, it is crucial to monitor potential complications like bleeding or vocal cord paralysis when resecting laryngeal hemangimoma.^28,29 A variety of tools can be used to identify and diagnose laryngeal hemangiomas. Previous studies have shown that laryngoscopy is effective for detecting the lesion, while MRI and CT scans are valuable for evaluating the anatomical impact, size, vascular characteristics, and morphology of the hemangioma.³⁰ In the case report and series section of our study, 5 out of the 19 received MRI evaluation, where 1 of these patients also underwent CT evaluation. Sixteen patients in Wu et al²⁴ also received either an MRI or CT evaluation.

The individual articles included in this systematic review treated patients who had capillary or cavernous hemangioma in the larynx. The main differentiating factor between these two types of hemangiomas is that cavernous hemangiomas are typically larger than capillary hemangiomas.^31,32 Cavernous hemangiomas are made up of larger blood vessels and blood-filled spaces, which makes them usually blue or purple in color and can be located deeper within the skin or internal organs. Capillary hemangiomas are composed of smaller capillary vessels, which make them smaller and red or pink in color, and are mostly found on the surface of the skin.^19,31,32 It is believed that for adult laryngeal hemangioma, the cavernous type is more common.³³ Although Wu et al²⁴ and Fang et al²³ did not provide clear details, the case reports and series that did specify the type of hemangioma included 5 cases of cavernous hemangioma and 3 cases of capillary hemangioma.

The output power of 10,600-nm CO2 is typically measured in watts. The wattage of low-power CO2 lasers typically ranges from 1 to 30 watts, and in this systematic review, the power ranged from 5 to 10 watts.³⁴ It is also important to note that CO2 microsurgery can be performed in a continuous or pulsatile manner. Continuous CO2 lasers produce a constant flow of energy, leading to the ablation of tissue without interruption at a specific output power. In contrast, pulsed or super-pulsed CO2 lasers produce high-energy pulses in brief intervals, where this limits damage to the surrounding tissue and offers better control over the targeted lesions.¹⁴

The primary goal of CO2 laser microsurgery is to achieve elevated tissue temperatures through the absorption of laser energy, which is highly absorbed by water in tissues, rapidly heating and vaporizing both intracellular and extracellular water. This process leads to tissue ablation as vaporization builds pressure, causing cell membranes to rupture and allowing for precise removal, layer by layer. The heat also affects nearby tissues, causing blood vessels to coagulate, which aids in controlling bleeding during the procedure.¹⁴ In contrast to conventional surgical methods, the laser’s pinpoint accuracy ensures precise targeting of tissues while safeguarding surrounding areas from harm. This results in the effective removal and resection of tissue, along with instant hemostatic coagulation.¹⁴

First invented in 1964, CO2 lasers have been used in multiple specialties and in various otolaryngology pathologies, although there have been few reports reviewing the outcomes and safety of CO2 laser treatment for adult laryngeal hemangioma given the rare nature of the disease. For patients with small laryngeal lesions, initial steps may involve general observation, whereas those with bigger masses may need medical intervention.¹⁰ Treatment modalities other than CO2 lasers have been used in treating adult and pediatric patients with laryngeal hemangioma, including the use of propranolol, corticosteroid injections, cold steel surgery, cryosurgery, and radiofrequency ablation.^10,12,28,35 However, the exact efficacies of these treatment modalities are uncertain because of a lack of randomized control trials and systematic reviews addressing laryngeal hemangioma specific to adult patients. Additionally, there is no standardized protocol for treating the disease.

For the case reports/series of this systematic review, we found that CO2 laser is efficacious and safe for laryngeal hemangioma patients. Only 1 of the 19 patients had recurrence of the hemangioma. In studies reporting symptom improvement following surgery, 12 out of 13 patients became asymptomatic, showed improvement in vocal function, or fully regained normal voice function. Furthermore, few patients had any complications following CO2 laser treatment, where 3 patients had intraoperative bleeding and 1 had unliteral vocal cord paralysis. Despite not observing any recurrences within this limited timeframe, the follow-up period may be insufficient for a comprehensive assessment. There is a chance that some of these patients may have experienced recurrences several months to years after their last follow-up. Laohakittikul and Srirompotong included follow-up durations of less than a year, with the five participants being monitored for only 1 to 4 months.¹⁹ Although there is no standard follow-up time, given the rare nature of the disease, one study assessing hepatic hemangioma found recurrence in patients between 4 and 17 years following initial resection.³⁶ Hepatic hemangiomas differ from laryngeal hemangiomas, but this example underscores the importance of extended follow-up periods to accurately assess treatment success.

Similar to CO2 lasers, potassium-titanyl-phosphate (KTP) lasers have been implemented in otolaryngology to treat various lesions in the larynx. KTP lasers use light energy with a wavelength of 532 nm, which is readily absorbed by oxidized hemoglobin.^24,37 Fang et al examined 25 adult patients with laryngeal and hypopharyngeal hemangioma who were treated with KTP laser + bleomycin injections.²² In their study, 10 patients experienced complete remission, 11 experienced partial remission, and 4 experienced stable disease, yielding an efficacy rate of 84.0%.²³ This was lower than the 100% and 90% efficacy rates that were reported for CO2 excision and CO2 coagulation + bleomycin, respectively. In the CO2 laser excision group, which included laryngeal and hypopharyngeal patients, all 7 individuals experienced complete resolution of their lesion while in the CO2 laser coagulation + bleomycin group, 9 had complete resolution (100% shrinkage), 9 had partial resolution (more than 50% shrinkage), and 2 had stable disease (less than 50% shrinkage).²³

Wu et al also assessed 9 patients with adult laryngeal hemangioma who were treated with KTP lasers.²⁴ Their study found an efficacy rate of 77.8%.²¹ This was also lower than the 90.9% efficacy rate associated with CO2 laser combined with pingyangmycin use, although statistical significance was not present. A systematic review comparing CO2 and KTP lasers for respiratory papillomatosis reported that KTP lasers had lower cure and complication rates, but the CO2 laser group experienced a lower remission rate. While KTP lasers have demonstrated effectiveness in treating diverse otolaryngology conditions, their utilization is limited by the cost of the equipment.³⁸ Although the use of CO2 lasers is more popular in otolaryngology procedures, more studies are needed to directly compare the patient outcomes of CO2 versus KTP lasers for laryngeal hemangioma patients.³⁹

Limitations

Aside from the power and mode of the CO2 lasers, this study did not compare the time of exposure, use of imaging guidance, and frequency setting of the laser equipment. These different settings may have had an impact on the efficacy of their use of different patients with laryngeal hemangioma across these studies.

Another limitation is the potential for publication bias. Studies that fail to demonstrate improvement or report adverse effects from CO2 treatment may be less likely to publish their results. Only cases suitable for surgery, based on factors such as anatomy, type of vascular malformation, presence of symptoms, or lower surgical risk due to location, may be selected, while many other cases are not treated surgically. Some lesions might be very small and asymptomatic, where providers may still choose CO2 treatment. All of these factors can introduce selection bias. Also, the majority of the studies in this systematic review are case reports or case series, which may limit the generalizability of findings for laryngeal hemangioma. While we recognize these biases, the rarity of adult laryngeal hemangiomas reflects the current state of the literature. Our goal is to provide a thorough overview of CO2 laser treatment for this condition, given the lack of a standard treatment protocol.

Conclusion

CO2 laser excision for adult laryngeal hemangiomas may be appropriate in carefully selected cases. Such cases might include smaller lesions that are accessible endoscopically and located where laser treatment minimizes the risk to nearby structures, like the vocal cords. Lesions with limited depth and superficial involvement could be better suited to complete resection with a lower likelihood of recurrence. Additional considerations, such as the necessity for surgery based on symptom severity—such as hoarseness, airway blockage, or difficulty swallowing—combined with assessments of functional cost versus benefit, resectability, and complication risk, should inform case selection. For patients with health conditions that make more invasive surgery less feasible, CO2 laser excision may offer a viable option. Ultimately, selecting appropriate cases is the surgeon’s responsibility, requiring a careful balance of these factors to ensure a safe and effective treatment approach.

Footnotes

Data Availability Statement

Data is public information and is available upon request.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics Statement

Not applicable because this is a systematic review and does not involve live human participants.

ORCID iD

Kenny Do

References

Martins

RHG

Neto

ACL

Semenzate

Lapate

. Laryngeal hemangioma. Braz J Otorhinolaryngol. 2015;72(4):574. doi:10.1016/S1808-8694(15)31009-0

Shukla

TS.

Recurrence of laryngeal hemangioma in an adult: a case report. Cureus. 2022;14(11):e31090. doi:10.7759/cureus.31090

Kawakami

Hayashi

Yoshimura

Ichihara

Nishikawa

Ichihara

Adult giant hemangioma of the larynx: a case report. Auris Nasus Larynx. 2006;33(4):479-482. doi:10.1016/j.anl.2006.05.010

Fowell

Monaghan

Nishikawa

Infantile haemangiomas of the head and neck: current concepts in management. Br J Oral Maxillofac Surg. 2016;54(5):488-495. doi:10.1016/j.bjoms.2016.02.031

Shen

Zhang

, et al Clinical characteristics, classification, and management of adult nasopharyngolaryngeal hemangioma. Laryngoscope. 2021;131(12):2724-2728. doi:10.1002/lary.29703

Grzesik

JK.

Current perspectives on the optimal management of infantile hemangioma. Pediatric Health Med Ther. 2017;8:107-116. doi:10.2147/PHMT.S115528

Okuda

Aoki

Ueda

, et al A rare case of adult vocal cord hemangioma: a case report and literature review. Cureus. 2023;15(8):e44042. doi:10.7759/cureus.44042

Kulkarni

Dwivedi

Singh

Tiwari

Hemangioma—a rare cause of laryngeal growth in an adult and its management with sclerotherapy and laser surgery: a case report. Indian J Otolaryngol Head Neck Surg. 2023;75(3):2485-2487. doi:10.1007/s12070-023-03765-7

Sharifi

Nazemieh

Moghadaszadeh

Supraglottic hemangioma as a rare cause of recurrent hemoptysis: a new treatment modality with argon plasma coagulation (APC). Tanaffos. 2014;13(2):50-52.

10.

Wang

Zhao

Zhu

Resection of a laryngeal hemangioma in an adult using an ultrasonic scalpel: a case report. Oncol Lett. 2015;9(6):2477-2480. doi:10.3892/ol.2015.3069

11.

Strong

Jako

Vaughan

Healy

Polanyi

The use of CO2 laser in otolaryngology: a progress report. Trans Sect Otolaryngol Am Acad Ophthalmol Otolaryngol. 1976;82(5):595-602.

12.

Garg

Verma

Chadha

Rastogi

Use of carbon dioxide laser in oral soft tissue procedures. Natl J Maxillofac Surg. 2015;6(1):84-88. doi:10.4103/0975-5950.168218

13.

Yumeen

Khan

Laser carbon dioxide resurfacing. In: StatPearls. StatPearls Publishing; 2023. Accessed October 25, 2023. http://www.ncbi.nlm.nih.gov/books/NBK560544/

14.

Omi

Numano

The role of the CO2 laser and fractional CO2 laser in dermatology. Laser Ther. 2014;23(1):49-60. doi:10.5978/islsm.14-RE-01

15.

Wellenstein

Honings

Schimberg

, et al Office-based CO2 laser surgery for benign and premalignant laryngeal lesions. Laryngoscope. 2020;130(6):1503-1507. doi:10.1002/lary.28278

16.

Vilaseca-González

Bernal-Sprekelsen

Blanch-Alejandro

Moragas-Lluis

Complications in transoral CO2 laser surgery for carcinoma of the larynx and hypopharynx. Head Neck. 2003;25(5):382-388. doi:10.1002/hed.10207

17.

Page

McKenzie

Bossuyt

, et al The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:10.1136/bmj.n71

18.

Alshaya

Alhejji

Aldkhyyal

Mesallam

TA.

Management of adult laryngeal hemangioma with CO2 laser. Saudi Med J. 2021;42(11):1252-1253. doi:10.15537/smj.2021.42.11.20210319

19.

Laohakittikul

Srirompotong

Adult vocal fold hemangioma: a case-series study and review of literature. J Voice. 2023;37(3):471.e1-471.e5. doi:10.1016/j.jvoice.2021.01.022

20.

Lomeo

McDonald

Finneman

Adult laryngeal hemangioma: report of four cases. Ear Nose Throat J. 2000;79(8):594, 597-598.

21.

Lucioni

Marioni

Della Libera

Rizzotto

Adult laryngeal hemangioma CO2 laser excision. A single institution 3-year experience (Vittorio Veneto 2001-2003). Acta Otolaryngol. 2006;126(6):621-626. doi:10.1080/00016480500452517

22.

Mesolella

Allosso

Mansueto

Fuggi

Motta

Strategies and controversies in the treatment with carbon dioxide laser of laryngeal hemangioma: a case series and review of the literature. Ear Nose Throat J. 2022;101(5):326-331. doi:10.1177/0145561320952191

23.

Fang

Wang

Morphology-guided treatment of adult laryngeal and hypopharyngeal hemangioma: FD-EENT experience. Eur Arch Otorhinolaryngol. 2023;280(9):4155-4163. doi:10.1007/s00405-023-08024-7

24.

Mao

Wei

Curative effect of chemotherapy, KTP lasers, and CO2 lasers combined with chemotherapy in the treatment of adult laryngeal hemangioma. Acta Otolaryngol. 2018;138(6):567-573. doi:10.1080/00016489.2017.1419577

25.

Martin

26.

Study Quality Assessment Tools | NHLBI, NIH. Accessed March 21, 2023. https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools

27.

Jiang

Chen

Xie

Smoking increases the risk of infectious diseases: A narrative review. Tob Induc Dis. 2020;18:60. doi:10.18332/tid/123845

28.

OuYang

Lou

Management of adult laryngeal hemangioma with low-temperature plasma radiofrequency coblation. Ear Nose Throat J. Published online July 3, 2023:01455613231185018. doi:10.1177/01455613231185018

29.

Shim

kyung Kim

MR.

Potassium-titanyl-phosphate (KTP) laser photocoagulation combined with resection using an ultrasonic scalpel for pharyngolaryngeal hemangioma via a transoral approach: case report and literature review. Am J Case Rep. 2021;22:e931042-1-e931042-10. doi:10.12659/AJCR.931042

30.

Rajab

Sindi

Ghanem

Bukhari

Zawawi

Acquired laryngeal hemangioma: a rare presentation in an adult. SAGE Open Med Case Rep. 2023;11:2050313X221146872. doi:10.1177/2050313X221146872

31.

Iwamoto

Jakobiec

FA.

Ultrastructural comparison of capillary and cavernous hemangiomas of the orbit. Arch Ophthalmol. 1979;97(6):1144-1153. doi:10.1001/archopht.1979.01020010598020

32.

George

Mani

Noufal

Update on the classification of hemangioma. J Oral Maxillofac Pathol. 2014;18(Suppl 1):S117-S120. doi:10.4103/0973-029X.141321

33.

Piombino

Broggi

Grillo

, et al Vocal cord hemangioma: a common tumor in an unusual localization. A case report with short review of literature. Indian J Otolaryngol Head Neck Surg. 2022;74(Suppl 3):5108-5110. doi:10.1007/s12070-021-02895-0

34.

Krupa Shankar

Chakravarthi

Shilpakar

. Carbon dioxide laser guidelines. J Cutan Aesthet Surg. 2009;2(2):72-80. doi:10.4103/0974-2077.58519

35.

Schwartz

Faria

Pawar

Siegel

Chun

RH.

Efficacy and rebound rates in propranolol-treated subglottic hemangioma: A literature review. Laryngoscope. 2017;127(11):2665-2672. doi:10.1002/lary.26818

36.

Zhu

Obeidat

Ouyang

Roayaie

Schwartz

Thung

SN.

Recurrent giant hemangiomas of liver: Report of two rare cases with literature review. World J Gastrointest Surg. 2012;4(11):262-266. doi:10.4240/wjgs.v4.i11.262

37.

Bachmann

Ruszat

The KTP-(greenlight-) laser–principles and experiences. Minim Invasive Ther Allied Technol. 2007;16(1):5-10. doi:10.1080/13645700601157885

38.

Yang

Xie

Seyler

BC.

Comparing KTP and CO2 laser excision for recurrent respiratory papillomatosis: a systematic review. Laryngoscope Investig Otolaryngol. 2022;7(4):970-981. doi:10.1002/lio2.871

39.

Yan

Olszewski

Hoffman

, et al Use of Lasers in Laryngeal Surgery. J Voice. 2010;24(1):102-109. doi:10.1016/j.jvoice.2008.09.006

Systematic Review: Effectiveness of Carbon Dioxide Lasers for Treatment of Adult Laryngeal Hemangioma

Abstract

Importance

Objective

Design/Methods

Setting

Participants

Intervention or Exposures

Main Outcome Measures

Results

Conclusion and Relevance

Keywords

Introduction

Review of the Literature

Methods

Study Design

Study Selection

Quality Assessment and Data Abstraction

Definitions

Results

Study Quality

Case Reports and Series Patient Characteristics

Case Reports

Case Series

Observational Studies

Discussion

Limitations

Conclusion

Footnotes

Data Availability Statement

Declaration of Conflicting Interests

Funding

Ethics Statement

ORCID iD

References