February 1998

Increased risk of symptomatic hemangiomas of the airway in association with cutaneous hemangiomas in a "beard" distribution.
Orlow SJ, Isakoff MS, Blei F; J Pediatr 1997; 131: 643-6.
[ see abstract below ]

Orlow et al evaluated the frequency of facial hemangiomas with asymptomatic upper airway or subglottic hemangiomas.

Of the 529 patients evaluated, 187 were pediatric patients and 27 of these children had hemangiomas in the "beard" distribution, i.e., periauricular, chin, lower lip, and anterior portion of the neck. Patients were scored on a simple scale of 1-5 based on the number of locations with an hemangioma (1 = 1 location, 5 = 5 locations). Sixteen of the 27 children had scores of 4 or 5, and of these 10 (63%) had symptomatic airway involvement!

This paper is important because it allows us to suspect clinically that there may be airway involvement based purely on the distribution and number of cutaneous hemangioma. My personal experience was a recent case of the child who had bilateral hemangioma of the eyelids (not the beard distribution). After passing an appropriate size endotracheal tube for a 2 year old (5.0) there was no leak even though the endotracheal tube easily passed with no resistance. We replaced it with a 4.5 and again no leak. We kept reducing sizes until a 3.0 allowed a leak at 30 cmH2O peak inflation pressure. Bronchoscopy revealed an greater than 50% occlusion of the airway. Upon questioning the parents stated that the child frequently had a "croupy" cough with colds but the pediatrician had suggested that the child would "out grow it".

The clinical caveat here is that the soft hemangioma will not offer any feel of resistance when passing the endotracheal tube because it is easily compressed. This emphasizes the importance of really checking for a leak around the endotracheal tube and not relying on the "feel" of how easily the endotracheal tube passes at the time of intubation. This paper, as well as my case, emphasizes that when you see more than one hemangioma on the face and particularly near the midline, one must have a high index of suspicion that there may be airway hemangioma as well.

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ABSTRACT