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BMJ Case Rep. 2010; 2010: bcr12.2009.2587.
Published online May 6, 2010. doi:  10.1136/bcr.12.2009.2587
PMCID: PMC3047577
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A clue on the face…
Joanne Spinks
Oxford Radcliffe Hospitals NHS Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK
Correspondence to Joanne Spinks, jspinks/at/doctors.org.uk
Abstract
A case of a 4-month-old girl with a subglottic haemangioma successfully treated with propranolol is reported.
A previously well 4-month-old girl presented with a 3-week history of biphasic stridor and difficulty in breathing. She had a cutaneous haemangioma on her forehead, which had been enlarging since she was 2 weeks old (figure 1). She had been misdiagnosed with croup when she presented 24 h earlier.
Figure 1
Figure 1
Patient with cutaneous haemangioma on her forehead.
Microlaryngoscopy and bronchoscopy revealed a circumferential subglottic haemangioma obstructing 90% of her airway (figure 2). She remained intubated after the procedure and dexamethasone 0.5 mg/kg twice daily and propranolol 1 mg/kg twice daily were started. Her forehead haemangioma reduced in size and she was extubated successfully 10 days later. Repeat microlaryngoscopy showed that the lesion had reduced substantially in size and was treated with CO2 laser ablation. Steroids were weaned off and she remains asymptomatic on propranolol.
Figure 2
Figure 2
Microlaryngoscopy revealing circumferential subglottic haemangioma obstructing 90% of airway
Subglottic haemangiomas are rare but have the potential to cause life-threatening complications. Affected infants are usually asymptomatic at birth but present with symptoms of a fixed upper airway obstruction as the lesion grows.1 Fifty per cent of infants with subglottic haemangiomas have cutaneous haemangiomas on the face.1 Bronchoscopy is necessary to make the diagnosis. Traditionally, steroids have been used to shrink lesions.1 However, propranolol has recently been shown to dramatically reduce the size of haemangiomas and should now be considered in proven cases.2,3
Clinicians need to be wary of diagnosing croup in infants under the age of 6 months especially if stridor is biphasic and cutaneous haemangioma is present.
Acknowledgments
Paediatric Respiratory and ENT Departments, John Radcliffe Hospital.
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.
REFERENCES
1. Rahbar R, Nichollas R, Gilles R, et al. The biology and management of subglottic hemangioma: past, present, future. Laryngoscope 2004; 114: 1880–91. [PubMed]
2. Denoyelle F, Leboulanger N, Enjolras O, et al. Role of propranolol in therapeutic strategy of infantile laryngotracheal hemangioma. Int J Pediatr Otorhinolaryngol 2009; 73: 1168–1172. [PubMed]
3. Leaute-Labreze C, Dumas de la Roque E, Hubiche T, et al. Propranolol for severe hemangiomas of infancy. NEJM 2008; 358: 2649–51. [PubMed]
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