http://elynsgroup.com Copyright: © 2016 Panda NK, et al. Open Access Research Article J Oto Rec Surg Journal of Otolaryngology and Reconstructive Surgery Page 1 of 4 ISSN: 2470-1041 Management of Head and Neck Arteriovenous Malformations - Team work Counts Naresh K. Panda 1* , Prabhat Thakur 1 , Ramesh K. Sharma 2 , Gautam Biswas 2 , Roshan Verma 1 and Niranjan Khandelwal 3 1 Department of Otolaryngology Head and Neck Surgery, PGIMER, Chandigarh, India 2 Department of Plastic Surgery, PGIMER, Chandigarh, India 3 Department of Radiodiagnosis and Imaging, PGIMER, Chandigarh, India Abstract Purpose: To demonstrate the management protocol in head and neck vascular malformation Methods: This is a retrospective review of 12 patients of arteriovenous malformation managed at a teaching hospital. Medical records were examined for age at first diagnosis, disease course, prior treatments, and age at presentation, management, therapeutic outcomes, impact on quality of life and photograph at time of presentation. Results: Twelve patients with head and neck arteriovenous malformation presented to our centre. There was equal distribution of males and females with an average age of presentation being 24 years (range 13-40 years). Ten patients out of 12 underwent embolization which was followed by surgery. Complete excision was achieved in eight cases while partial resection was achieved in two cases. Three patients had complications while getting treated. Conclusions: Head and neck AVM can be presented as expansile, invasive and locally aggressive lesions which require detailed evaluation and multidisciplinary approach for treatment. Keywords: Vascular Malformation; Surgical Excision; Multidisciplinary Approach Introduction Arteriovenous malformations (AVM) are congenital malformation sharing communication between arteries and veins (arteriovenous shunting) which lack normal capillary networks. A nidus is an area with abnormal vasculature and shunting [1]. The initially quite lesion may progress to expansile mass during puberty or adolescence. Once it progresses, it causes bleeding, ulceration, pain, and cardiac volume overload [2-5]. Complete removal of the lesion is the treatment of choice [2- 5]. Complete removal may be difficult due to diffuse involvement in the head and neck region. They are also known to increase in size during adolescence and after an attempted treatment [5-7]. The various modes of treatment that are available commonly include either transarterial vessel occlusion or ablative surgery. Single modality treatment may not be able to result in significant long- term reduction in clinical features. The combination therapy is now considered to be the treatment of choice [2]. We have managed in our centre during the last ten years. Incomplete removal and resultant residual lesions have led the patients to attend our hospital for treatment. The aim of the present series is to present the course of the AVM presenting in our Institute and their surgical management. Methods This was a retrospective analysis of 12 cases of arteriovenous malformation of head and neck region that were managed in our department between August, 2004 and December, 2014. The records were evaluated for the age of presentation, previous surgery and treatment options. The AVMs were subsequently staged using the Schobinger staging system (Table 1). The records were reviewed for various variables like age, sex, past treatment and progression. The treatment and outcome of the lesions were also looked at. A prior consent was taken to take pictures of the patients. The diagnosis of arteriovenous malformation was established by getting clinical history, performing physical examination, obtaining radiographic images, and pathological results. MRI and arteriography revealed feeding arteries with dilated draining veins around a centralized nidus in each of these patients. Flow voids suggestive of fast flow lesions, were present on MRI/MR angiography. Multiple feeding arteries were present in each arteriovenous malformation. Angiography was followed by embolization in the treatment phase of some patients. All the patients underwent diagnostic angiography to verify the associated shunt and know the feeding arteries. The lesions were classified as AVMs if there was a clearly identifiable nidal component; otherwise they were classified as fistulas. PVA (polyvinyl alcohol) and Gel foam were the most common materials used. Surgical resections were performed with the aim to remove the session completely. Reconstruction included both local and free flaps. The final diagnosis was confirmed by histopathological examination. Results Twelve patients with head and neck arteriovenous malformations presented to our centre. Among them six were male and six were female. The average age at presentation was 24 years (range 13-40 years). The summary of clinical features is presented in table 2. A diagnosis of haemangioma was most commonly made before they presented to our centre. The continuous growth and local invasion prompted all patients to search for a second medical opinion. The photographs of two patients illustrating the clinical presentation of AVMs are shown in Figure 1-8. The data regarding the extent of disease at the time of presentation at our centre is also detailed in table 2. Each patient Received Date: : May 07, 2016, Accepted Date: June 20 2016, Published Date: June 30, 2016. *Corresponding author: Naresh K. Panda, Department of Otolaryngology Head and Neck Surgery, PGIMER, Chandigarh, India, Tel: +91-941-777-0289; E-mail: npanda59@yahoo.co.in Stage 1 (quiescence) Warm, pink-blue, shunting on Doppler examination Stage 2 ( expansion) Enlargement, pulsation, thrill, bruit, tortuous veins Stage 3 (destruction) Dystrophic skin changes, ulceration, bleeding, pain Stage 4 (decompensation) Cardiac failure Table1: Schobinger staging of arteriovenous malformation [14].