The Laryngoscope VC 2016 The American Laryngological, Rhinological and Otological Society, Inc. Foamed Bleomycin Sclerosis of Airway Venous Malformations: The Role of Interspecialty Collaboration Ezana Azene, MD, PhD; Sally Mitchell, MD; Martin Radvany, MD; Nishant Agrawal, MD; David Eisele, MD; Clifford Weiss, MD Objectives/Hypothesis: To assess clinical outcomes of patients with airway venous malformations treated with percuta- neous sclerotherapy (VMPS). We highlight the role of foamed bleomycin as a less inflammatory sclerosant and the importance of collaboration between interventional radiology and otolaryngology–head and neck surgery (OHNS). Study Design: Retrospective, consecutive, single-center series. Methods: Sixteen airway VMPS treatment sessions were performed (5 patients). Endoscopic needle guidance was per- formed by OHNS. Sclerosants included ethanol and foamed bleomycin. The following data were tabulated for each patient: hospital length of stay (LOS), clinical response, and the presence/absence of airway swelling requiring prolonged intubation. Univariate analysis was performed. P < 0.05 was considered significant. Results: Thirty-one percent (5 of 16) of treatments required endoscopic guidance. Eighty-seven percent (7 of 8) of air- way VMs treated with ethanol caused significant airway swelling compared to 0% (0 of 8) of airway VMs treated with bleo- mycin (P 5 0.0004). The LOS was significantly greater for ethanol (5 6 0.3 days) than for bleomycin (1 day, P 5 0.001). Ninety-four percent (15 of 16) of airway VM treatments had at least a partial clinical response. There was no significant dif- ference in clinical response between ethanol and bleomycin (P 5 0.30). Conclusion: Endoscopic and image-guided needle placement may be necessary to treat deep airway VMs. Bleomycin may cause less significant airway swelling than ethanol. This may reduce hospital LOS and prolonged intubation. Our results should be interpreted with caution because this is a very small retrospective study. Additional investigation is needed to establish safety and efficacy of foamed bleomycin. Key Words: Vascular anomaly, venous malformation, bleomycin, percutaneous sclerotherapy. Level of Evidence: 4. Laryngoscope, 00:000–000, 2016 INTRODUCTION Venous malformations (VMs) are nonpulsatile, slow- flow vascular anomalies. 1 They are the most common symptomatic vascular malformation. Symptoms vary depending on body location, size, and extent of tissue involvement. Symptoms may include swelling, pain, bleeding, ulceration, dysphagia, odynophagia, and even life-threatening airway obstruction. 2,3 Symptoms may also wax and wane with hormonal changes (e.g., puberty, pregnancy) or occur only with trauma. 4 Approximately 40% of VMs occur in the head, face, and neck, 5 with a special predilection for the airway (oral cavity, pharynx, and larynx) and muscle groups. 6 Airway VMs pose unique challenges. Endoscopy is often needed to visualize these lesions. Posttreatment swelling can result in airway compromise, necessitating pro- longed intubation or tracheostomy. Venous malformations can be categorized into four venographic types that have important implications on treatment and prognosis. 7,8 Type I is an isolated VM without visible venous drainage. Type II VMs drain into normal veins. Type III VMs drain into dysplastic veins. Type IV VMs consist of large, ectatic veins. Types I and II respond best to percutaneous sclerotherapy. 8,9 Types III and IV are associated with a greater risk of complica- tions due to systemic drainage of sclerosant and the greater volume of sclerosant needed to fully treat the VM. 7 Venous malformation percutaneous sclerotherapy (VMPS) is the current accepted treatment for VMs. 5,7,10,11 Large lesions may require multiple treat- ments, primarily due to sclerosant dose limitations. 5,10 Surgical excision can also be performed. However, com- plete resection can be very challenging because bleeding is difficult to control and VMs typically infiltrate multi- ple tissue planes. 12 Resection is more successful in treat- ing small, well-defined lesions (often after performing From the Department of Radiology (E.A., S.M., M.R., C.W.); the Department of Otolaryngology–Head and Neck Surgery (N.A., D.E.), Johns Hopkins School of Medicine, Baltimore, Maryland; the Department of Radiology, Gundersen Health System (E.A.), La Crosse, Wisconsin; and the Department of Endovascular Neurosurgery, WellSpan Health (M.R.), York, Pennsylvania, U.S.A. Editor’s Note: This Manuscript was accepted for publication April 12, 2016. Presented at the 20th International Society for the Study of Vascu- lar Anomalies International Workshop, Melbourne, Australia, April 2–4, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Clifford Weiss, MD, Interventional Radiol- ogy Center, Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD 21287. E-mail: cweiss@jhmi.edu DOI: 10.1002/lary.26077 Laryngoscope 00: Month 2016 Azene et al.: Bleomycin Sclerosis of Venous Malformations 1