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CASE REPORT Table of Contents  
Ahead of print publication
Transoral robotic excision of a large tongue hemangioma


1 Department of ENT and Head and Neck Surgery, Indraprastha Apollo Hospitals, New Delhi, India
2 Department of Pathology, Indraprastha Apollo Hospitals, New Delhi, India

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Date of Submission18-Jun-2021
Date of Decision22-Jul-2021
Date of Acceptance23-Jul-2021
Date of Web Publication18-Oct-2021
 

  Abstract 


Hemangiomas are usually congenital benign vascular tumors mostly found over the skin of head and neck. Tongue hemangiomas are relatively rare. Its treatment may include corticosteroid and beta-blocker therapy, interferon, sclerotherapy using bleomycin, cryotherapy, etc., but surgical therapy is the treatment of choice for solitary hemangioma. Transoral robotic surgery for hemangioma in the anterior tongue can be an added indication for robot-assisted procedure. Robotic technology offers numerous advantages and it can be a promising alternative in dealing with difficult oral cavity lesions like hemangioma.

Keywords: Hemangioma, tongue, transoral robotic surgery


How to cite this URL:
Nagpal K, Naruka SS, Rana N, Sobti P. Transoral robotic excision of a large tongue hemangioma. Apollo Med [Epub ahead of print] [cited 2021 Dec 2]. Available from: https://www.apollomedicine.org/preprintarticle.asp?id=328540





  Introduction Top


Hemangiomas are usually congenital benign vascular tumors seen in newborns, infants, and children. They are mostly found over the skin of head and neck. Oral cavity and oropharyngeal hemangiomas are uncommon. Lips are the most common site involving oral cavity whereas tongue hemangiomas are relatively rare.[1] Vascular lesions of oral cavity may bleed repeatedly or impair mastication, deglutition, articulation, and speech.

Robotic surgery in the form of transoral robotic surgery (TORS) has become a widespread technique for the treatment of oral cavity and oropharyngeal pathologies. TORS for removal of oropharyngeal tumors has been well established and its application has increased in recent years.[2]

This study aims to present a case of large hemangioma of anterior of tongue excised using the novel technique of robotic technology.


  Case Report Top


A 24-year-old male presented with a soft swelling over anterior two-thirds of tongue for 6 months. The patient gave a history of gradual increase in size of swelling over these 6 months. It was associated with little difficulty in the speech. There was no history of pain or similar swelling in head and neck.

On examination, there was a single dome-shaped bluish-purple swelling involving the right side of anterior tongue crossing the midline [Figure 1]. The posterior extent was just anterior to circumvallate papillae/terminal sulcus and anteriorly extending up to 3 cm posterior to the tip of tongue. It was ovoid in shape, surface was smooth, and borders were well defined. On palpation, it was soft in consistency, compressible, measuring around 4 cm × 3 cm, nonmobile, and nontender with no palpable thrill. Magnetic resonance imaging (MRI) revealed a lobulated T1 isointense and T2 hyperintense lesion noted involving the right side of tongue anteriorly with multiple T2 hypointense foci, compatible with flow voids. Lesion measured 3.6 cm × 2.3 cm × 2.7 cm [Figure 2]a and [Figure 2]b.
Figure 1: Dome-shaped bluish-purple swelling involving the right side of anterior tongue

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Figure 2: (a and b) CEMRI showing lobulated T1 isointense and T2 hyperintense lesion involving the right side of tongue anteriorly with multiple T2 hyopointense foci, compatible with flow voids. Lesion is showing restriction on DW images and intense enhancement of postcontrast images. Lesion measures 3.6 cm × 2.3 cm × 2.7 cm

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On the basis of clinical examination and MRI, a diagnosis of hemangioma was made and transoral robotic excision with lingual artery ligation was planned.

The patient was taken up under general anesthesia and nasotracheal intubation was done. Two Doyne's molar retractors at both angle of mouth were used. The tongue was retracted anteriorly and stabilized using 1-0 silk tie. This improved the visualization and adequate exposure of the tongue hemangioma was created. As the lesion was big and involving the anterior tongue, any type of tongue blade was not used. The da Vinci Si robot was docked. A 8-mm 30° endoscope facing down, Maryland forceps in left, and monopolar cautery in right arm of robot were used [Figure 3]. Dissection started with mucosal incision along the margin of the hemangioma. The dissection continued till the inferior limit, which was achieved within the deep muscles of the tongue. It was excised circumferentially controlling bleeding from microvasculature which was clearly visible through magnified 3-D vision of robot. Main feeder of the hemangioma and right lingual artery were identified and ligated using robotic clipper. The specimen was completely excised in toto with minimal bleed and sent for histopathological examination. The primary closure of the defect was done using 3-0 vicryl. Almost left half and tip of the tongue was preserved. Oral clear cold fluids were started after 6 h of the surgery. The patient discharged next day of surgery. Postoperative, the tongue movement and speech were normal. Oral antibiotics, supportive treatment, and cold liquids and semisolid diet were advised. Histopathology was suggestive of hemangioma [Figure 4]a and [Figure 4]b. The patient was in regular follow-up for 4 months, and all the tongue movements were preserved without any recurrence [Figure 5]a and [Figure 5]b.
Figure 3: Docking of da Vinci Si robot showing adjustments of camera with two robotic arms and Doyne's retractor for exposure of lesion

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Figure 4: (a) H and E, ×40, section of tongue showing a lesion composed of variable-sized vascular channels in the subepithelium with surrounding stroma showing mild chronic inflammation. (b) H and E, ×100, section showing vascular channels lined by flattened layer of endothelial cells

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Figure 5: (a and b) Showing postoperative images of tongue on the 10th postoperative day and after 3 months, respectively

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  Discussion Top


There are numerous potential applications of TORS. Some are comparatively easier to perform whereas some pose potential challenges. Oral, oropharyngeal, and laryngeal surgeries may have considerable challenges because of difficult anatomical access. Hemangiomas at these anatomical sites are one of the challenges which can be easily handled with robotic assistance.

Hemangiomas are developmental vascular lesions and head and neck constitute 50% of them.[3] In head and neck, they are seen over lips, tongue, buccal mucosa, and palate. The smaller lesions can be left for follow-up. For others, treatment may include corticosteroid and beta-blocker therapy, interferon, sclerotherapy using bleomycin, cryotherapy, laser therapy, radiotherapy, and surgical therapy.[4],[5] In most of the cases like isolated vascular lesions of tongue, surgery is the therapy of choice.[6],[7] With the availability of robotic technology, TORS is available for such lesions. It can be adopted in a safe way to resect the vascular lesion of oral cavity like tongue hemangioma. For surgical excision of tongue hemangioma, depth of the soft tissue involvement should be assessed.

In our case, the hemangioma was located inside the muscle layers of tongue dorsum. The lesion was meticulously dissected using robotic technique, and complete evisceration was possible with 10 times magnification.

The advantage of TORS in dealing with hemangioma is that there is a better control over bleeding, with simultaneous cautery and coagulation functions that are in-built allowing a neat dissection.[8] All the functions are available near the feet of the surgeon in the form of push buttons in the surgeon console. The da Vinci robot has high definition camera providing three-dimensional magnified view of lesion helping in resecting the lesion precisely. It helps in providing better depth perception of lesion and associated anatomical structures to avoid damage. Its tremor filtration technology helps in avoiding dangerous movement, particularly in lesions like hemangioma.


  Conclusion Top


Surgical treatment is the best option for tongue hemangiomas, and robotic technique allows clear and neat dissection with better control over bleeding. At the moment, robotic technology offering a promising result in oral cavity and oropharyngeal pathologies and offering a promising alternative to conventional surgeries.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Balaji SM, Balaji P. Large hemangioma of the tongue. Indian J Dent Res 2020;31:979-82.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Cammaroto G, Stringa LM, Zhang H, Capaccio P, Galletti F, Galletti B, et al. Alternative Applications of Trans-Oral Robotic Surgery (TORS): A systematic review. J Clin Med 2020;9:201.  Back to cited text no. 2
    
3.
Kamala KA, Ashok L, Sujatha GP. Cavernous hemangioma of the tongue: A rare case report. Contemp Clin Dent 2014;5:95-8.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Dziegielewski PT, Durmus K, Ozer E. Transoral robotic surgery for the excision of base of tongue vascular lesions. Head Neck 2015;37:1211-2.  Back to cited text no. 4
    
5.
Atkins JH, Mandel JE, Mirza N. Laser ablation of a large tongue hemangioma with remifentanil analgosedation in the ORL endoscopy suite. ORL J Otorhinolaryngol Relat Spec 2011;73:166-9.  Back to cited text no. 5
    
6.
Ohlms LA, Jones DT, McGill TJ, Healy GB. Interferon alfa-2a therapy for airway hemangiomas. Ann Otol Rhinol Laryngol 1994;103:1-8.  Back to cited text no. 6
    
7.
Izadpanah A, Izadpanah A, Kanevsky J, Belzile E, Schwarz K. Propranolol versus corticosteroids in the treatment of infantile hemangioma: A systematic review and meta-analysis. Plast Reconstr Surg 2013;131:601-13.  Back to cited text no. 7
    
8.
Nagpal K, Malik NU, Goyal K, Ansari SH, Rawat V, Kashyap V. Transoral robotic excision of hemangioma tongue in rare case of maffucci syndrome. Am J Otolaryngol Head Neck Surg 2019;2:1071.  Back to cited text no. 8
    

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Correspondence Address:
Kalpana Nagpal,
Department of ENT and Head and Neck Surgery, Indraprastha Apollo Hospitals, New Delhi
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0976-0016.328540



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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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