A Child with a Large Facial Hemangioma and Stridor
A 3-month-old female infant is brought to the clinic with a rapidly growing red, raised lesion on the left cheek and upper lip that appeared at 2 weeks of age. The lesion measures 5 cm × 4 cm and is warm and tense. The infant has developed a hoarse cry and mild stridor over the past week. She is otherwise healthy, feeding well, and thriving. There is no family history of vascular anomalies. Examination reveals a deep red, non-pulsatile mass with superficial ulceration at the medial canthus. The parents are anxious about the appearance and the breathing noise.
1. What is the diagnosis, and what is the significance of the stridor?
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The diagnosis is infantile hemangioma (IH) in the proliferative phase. The stridor and hoarse cry suggest airway involvement, likely a subglottic hemangioma, which is a potentially life-threatening complication. IHs in a 'beard' distribution (chin, neck, lower lip) are associated with airway hemangiomas. This infant's lesion involves the upper lip and cheek, which is not classic beard, but the stridor warrants urgent evaluation. Airway hemangiomas can cause obstruction and require immediate intervention.
2. How would you manage the hemangioma and the airway concern?
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The infant needs urgent referral to otolaryngology for airway evaluation (flexible laryngoscopy) to confirm subglottic hemangioma. For the cutaneous hemangioma, given the large size and risk of disfigurement, systemic therapy is indicated. Oral propranolol (2–3 mg/kg/day) is first-line, with initiation under monitoring for bradycardia and hypotension. If airway obstruction is significant, systemic corticosteroids (prednisolone 2–3 mg/kg/day) may be used as a bridge, and propranolol can be started. Laser therapy may be considered for ulceration or residual lesions. The parents should be counseled on potential side effects and the need for regular follow-up.
3. What factors would influence the duration of treatment and follow-up?
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Propranolol is typically continued until the hemangioma stops growing and begins to regress, usually around 12–18 months of age, but may be extended if the lesion is still proliferative. Follow-up should include regular assessment of size, color, and ulceration, as well as monitoring for side effects (hypoglycemia, bradycardia, hypotension). The airway hemangioma requires close collaboration with ENT. After treatment, the child may have residual fibrofatty tissue or telangiectasia, which can be addressed later with laser or surgery. Psychosocial support for the family is important.