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Case Report

Capillary Hemangioma of The Nasal Septal

By
IA Alit Widiantari

Supervisor
dr I Gde Ardika Nuaba, Sp.T.H.T.K.L.(K),FICS
Hemangioma is a benign tumor of blood vessels, localized,
congenital

Approximately 20% of benign tumors in the nasal cavity are


hemangiomas, in which these tumors can occur in the nasal
septum (65%)

hemangioma is divided into capillary hemangioma,


cavernous hemangioma and mixed hemangioma type
Ash and Old (1950) stated that hemangioma in the nasal septum can
cause epistaxis and nasal obstruction.

Excision of tumor is the main therapy

The location of the tumor is very rare in the nasal septum. It was
reported that a case of capillary hemangioma in left nasal septum in a
16-year-old male who had performed surgery for tumor resection
• benign tumors that
occur due to
disturbances in the
development and
DEFINITION formation of blood
vessels and can occur
in any blood vessel
tissue
± 1-3% in neonates and ± 10% in infants up to 1 year of age

more in females than males, with a 3: 1 ratio and more


often on white races

women are often found at age above 40 years. While


in men under less than 18 years.

The most common location of hemangioma in the


head and neck area is 59%.

20% of benign tumors in the nasal cavity are hemangiomas,


whereas these tumors can occur in the nasal septum (65%),
lateral walls (18%) and vestibulum (16%).
Increased levels of
angiogenesis factors and /
or decreased levels of
angiogenesis inhibitors
unclear such as Gamma Interferon
(Ύ-IF), Tumor Necrosis
Factor-beta (TNF-β) and
Transforming Growth
Factor-beta (TGF-β)

trauma, viral oncogen physical, mechanical


and arteriovenous and chemical irritants,
malformations may hormonal influences,
also contribute to the are also thought to be
process of the cause of abnormal
hemangioma proliferation
PATOGENESIS

initially, the tumor appears as a cell grows and begins to


divide-form new cells

nutrients from nearby blood vessels, but as the cells


continue to divide, so they must have their own blood
vessels

the angiogenesis process is required, among others,


Vascular Endothelial Growth Factor (VEGF)
HEMANGIOMA KAPILER
• frequent lesions, more superficial
lesions
Capillary • a pink papule area by forming lobes
hemangioma
• epithelial cells clustered with multiple
capillary channels.

• rarely found and the location of the


Cavernous lesion deeper
hemangioma • visible vascular tract with a large
layer of endothelial cells

• Usually regarding the parotid gland


Mixed in children, arise soon after birth.
hemangioma
type • visible channels of large and small
blood vessels are intermittent.
HEMANGIOMA KAPILER

consisting of: a) capillary hemangioma in children (nevus vasculosus,


strawberry nevus); b) pyogenic granuloma; c) cherry-spot (ruby-spot),
senile angioma.

often together with other abnormalities and form a syndrome,


among others: Kasabach Merrit syndrome, Sturge-Weber
syndrome, Klippel-Trenaunay-Weber syndrome (nevus
vaskulosus hypertrophicus) and Blue Rubber Bleb Nevus
syndrome.

epithelial cells clustered with multiple capillary channels. Capillary


hemangioma consists of new capillaries containing blood and forming
a webbing.
DIAGNOSIS

anamnesa

PHYSICAL EXAMANATION

unilateral epistaxis and SUPPORT EXAMANATION


nasal congestion
red spots that arise after
birth, bright red color
when strawberry type
Histopatology
CT scan/ MRI
in deep nasal cavities
that can range from a
Positron emisi
few millimeters to more
tomography (PET)-CT
than 2 centimeters
DIFERENTIAL DIAGNOSIS

limfangioma
traumatic Kaposi Melanoma
hematoma sarcoma maligna
MANAGEMENT

Conservative

Operative
MANAGEMENT

• observation to see if the hemangioma is


OBSERV enlarged in the first months, then reach the
ATION maximum and regress until the age of 5
years.

SURGERY • if it interferes with function


and aesthetics

Another • steroid therapy, bleomycin


approach and propranolol
Extensive sclerotherapy,
cryotherapy
steroid,
tumor resection bleomycin and
• 1 mg / ml propranolol
• external pingyangmycin
injection is safe, therapy
approach with
effective and • suppress the
transpalatal, inexpensive for
transmandibular, development of
infantile hemangioma
lateral rinotomy, hemangioma and
also can with maxilofacial therapy before surgical
nasoendoscopic • necrosis due to cell
approach. freezing and
• preoperative liquefaction
preparation is
embolization
PROGNOSIS

The recurrence rate of


this disease after 5
years is reported to be
a good prognosis in less than 7.5%
the event of
spontaneous
involution
Patient, male, 16 years
old, student, came to
the ENT-HNS clinic
Sanglah on May 27th,
2017 complaining of He suffered
nasal congestion since
6 months. A tumor nosebleeds
developed in the left of left nostril,
nostril and enlarges but stopped a
slowly few moments
later.
Inspection: left nasal cavity
mass (+), secret (+), smooth
surface bleeding easily, other structures
can not be evaluated
Management

The result of
Biopsy of nasal hystopatology
cavity tumor on corresponds to
July 19, 2017 the morphology
attached an of lobular
anterior nasal capillary
dressing of nasal hemangioma
cavity S for 2 days
• Capillary
hemangioma
in the left
nasal
septum
Pre opration : laboratory test

MANAGEMENT
and chest x-ray, consultation
internis and anesthesiologist

Result : there is no
contraindication

Wide resection at 6th


August 2017
6 Aug. 2017, post wide resection,
therapy: 2x500 mg of sefadroxil,
paracetamol 3x 500mg

August 8, 2017, aff anterior nasal


dressing, out of hospital

August 13, 2017, control,


complaint (-), looks minimal crust
on the nasal cavity sinistra
Discussion

Literature Case
• ♀>♂, 3:1 • A male, aged 16
• Hormonal factor male years old
increase before 18y.o,
and female increase
after 40 y.o
Discussion
Literature Case
• The nature of benign tumors in the • complained of Tumor arise
nose is enlarged slowly since childhood and began to
• Typical symptoms of nasal interfere with breathing since 6
obstruction and recurrent epistaxis months ago
• Complained nasal congestion,
recurrent epistaxis, rinorrhea
Discussion
Literature Case
• The recommended • CT scans were
investigation is Ct scan, performed in contrast
MRI and PET scan and results is mass in
the left nasal cavity
with good bone
condition
• MRI and PET scans
are not performed
Discussion
Literature Case

• Histopathological examination is • The histopathologic outcome


a standard gold where in the of this case where on the
capillary hemangioma found new connective tissue stroma
capillaries containing blood and appears proliferation of blood
form a webbing vessels to form lobular
structures and visible blood
vessels coated endothelial
cells shaped kuboid to flat,
large blood vessel size and
contains erythrocytes and
there is inflammatory cell
spread
Discussion
Literature Case
• Most cases of hemangioma are • In this case there has been
observed until spontaneous extensive tumor resection, the
regression occurs indication is the presence of
• Surgical indications are when large nasal obstruction.
tumor size and disrupt function
and aesthetics
Discussion
Literature Case
• Surgery performed is tumor • In this case, extensive tumor
resection of the nasal of resection has taken part of a
perichondrium and mucosa, to healthy tissue.
reduce the rate of recurrence
Conclusion
A case of lobular capillary hemangioma in the left nasal septum had
reported

Diagnosis is very difficult because clinical manifestations are similar


to other benign nose tumors

The prognosis is good, it is based on its relapse.

Preoperative angiography should be examined with embolization, as


it is helpful in terms of showing the anatomy of blood vessels and
can reduce the amount of blood lost during surgery and reduce
morbidity
THANK YOU

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