THESIS SYNOPSIS

DR. ANKUR THAKRAL

DEPARTMENT OF ORAL AND MAXILLOFACIAL

SURGERY

A.B. SHETTY MEMORIAL INSTITUTE OF DENTAL SCIENCES, DERALAKATTE, MANGALORE – 575018

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

4th T BLOCK, JAYANAGAR,BANGALORE,KARNATAKA

ANNEXURE-11

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / DR. ANKUR THAKRAL
POST GRADUATE STUDENT,
DEPT OF ORAL AND MAXILLOFACIAL
SURGERY,
A.B.SHETTY MEMORIAL INSTITUTE OF DENTAL SCIENCES.
DERALAKATTE- MANGALORE – 575 018
2. /

NAME OF THE INSTITUTION

/ A.B.SHETTY MEMORIAL INSTITUTE OF DENTAL SCIENCES.
DERALAKATTE – MANGALORE – 575 018
3. / COURSE OF THE STUDY AND SUBJECT / MASTER OF DENTAL SURGERY
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY.
4. / DATE OF ADMISSION TO COURSE / JUNE -2008
5. / TITLE OF TOPIC
“CERVICOFACIAL HEMANGIOMAS. CLINICAL MANAGEMENT AND TREATMENT OUTCOMES : A RETROSPECTIVE STUDY’’
6. / BRIEF RESUME OF THE INTENDED STUDY:
6.1 NEED FOR THE STUDY:
Hemangiomas have existed as a clinical entity for over 100 years. They are the most common congenital deformity observed in infants and children. However, they have been the subject of much controversy and confusion over the years.Hemangioma is a true neoplasm of infancy, a common birthmark presenting a challenge to the surgeons. During the first several months of the child’s life, these hemangiomas begin to grow rapidly & they usually continue to do so for 4 to 6 months. When involution occurs, the process is usually completed by the child’s seventh year. Therefore, a strong opinion developed in the mid-20th century that appropriate treatment for hemangioma was no treatment, this became known as benign neglect.
However symptomatic problems such as ulceration, bleeding, infection & residual skin changes which may be disfiguring, require early intervention.Also children begin to develop self awareness at 18 to 24 months of age. Therefore, the psychosocial impact on a child with a facial hemangioma or its resultant scar can not be underestimated.
The past decade has witnessed a revolution in the understanding and treatment of these vascular lesions. Previous complacency in treatment is changing to a more proactive approach. A number of treatment modalities are available for the management of hemangiomas with inevitable complications.These include observation, corticosteroid therapy, compression, laser, radiation therapy, interferon α-2a, surgery and the use of sclerosing agents.
The question is how to identify those lesions that are most likely to require treatment and treat them early if possible. And also the question is which treatment modality is best suited for that particular individual and what is the treatment outcome.Therefore, a study that will discuss various therapeutic options with emphasis on the timing of intervention and type of treatment and also focusing on correlation between various managements of hemangiomas and their outcomes is needed. It will enable an oral and maxillofacial surgeon to develop an aesthetic approach in the management of hemangiomas and also alleviate the considerable burden of disease carried by the child and the family.
6.2 REVIEW OF LITERATURE
A retrospective study of 245 patients with175 hemangiomas located on the head & neck treated from May 1981 to April 1994 was conducted.Five groups of patients were defined based on clinical management. Group I observation, Group II steroid treatment, Group III excision and reconstruction, Group IV laser therapy and Group Vwas combined therapy. Treatment period ranged from 1 month to 11 years. The outcomes of each patient were evaluated and their results showed a statistically significant difference in volume, color and texture depending on management. The study also concluded that it is desirable to do definitive treatment whenever possible, thereby minimizing morbidity, both functional and psychological1.
In a study conducted at Albany Medical College, New York, charts of the patients were reviewed for diagnosis and management of 208 new patients with vascular birthmarks was recommended. For the purpose of medical and/or surgical management, hemangiomas were divided into either the proliferative or involution phase. Based on patient population, available data and the current literature, they concluded that an early evaluation and accurate diagnosis in infants with a vascular birthmark are important. Furthermore, intervention by way of systemic steroids, laser therapy or surgical debulking is appropriate and safe in a select group of patients presenting with a proliferating hemangioma and in patients with an involuting but disfiguring hemangioma. Also they presented an algorithm to assist the clinician with the management of hemangioma2.
The medical records, operative notes and radiographs, and patient satisfaction survey data from 38 patients with hemangiomas undergoing invasive treatment have been retrospectively reviewed in a study. Sodium tetradecylsulfate sclerotherapy was a sole therapy in 12 patients and was used in combination with surgical ablation in 16patients. 10 tumors were completely removed with ablative surgery. Their results showed that combined application of sclerotherapy & conservative ablative surgery had a favorable functional & aesthetic outcome in patients with incompletely involuted hemangioma. Patient satisfaction surveyconfirmed that benefit was perceived by the vast majority (88%)3.
In a study conducted at Taiwan, the effect of intralesional corticosteroid therapy in the treatment of 155 head & neck hemangiomas was reviewed. 3 to 6 injections of triacinolone acetonide in monthly intervals were given and the results were assessed 1 month after completion of the treatment. 85% of the superficial, 75% of the deep and 60% of the combined hemangioma showed more than 50% reduction in the volume. The post injection complication rate was 6.4% in this series4.
In a study, 31 cases of cavernous hemangioma in different sites were treated with intratumoral ligation. The author describes details by which interception of the blood supply to the hemangiomas is achieved and also breakdown of the angiomatous mass into segments by the occlusion of vascular channels, thus completely interrupting the intratumoral blood flow. The results with follow- up periods of 1-8 years prove its efficacy5.
In a study, 11 patients with a total of 12 hemangiomas of the head and neck and 1 involving a middle finger were treated. One or more lasers were used in the treatment of all of the patients except 2. Of the 13 hemangiomas treated, 12 responded. No evidence of scarring was noted as a consequence of treatment. They concluded that the recent emergence of laser technology and more specifically that of pulsed yellow light have added a dimension to the physician’s ability to treat hemangiomas. These devices have enabled physicians to move away from nonselective tissue destruction to a more selective photothermolysis6.
6.3OBJECTIVES OF THE STUDY
  1. To study different treatment modalities with emphasis on timing of intervention and type of treatment.
  2. To find out treatment outcomes following various managements of hemangiomas.

7 / MATERIALS AND METHODS
7.1 SOURCE OF THE DATA
The study is set up in A.B. Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore.For the purpose of this study, aretrospective review of patients with confirmed diagnosis of hemangiomasreported from 2001 to 2008 in A.B. Shetty Memorial Institute of Dental Sciences will be done.
7.2 METHOD OF COLLECTION OF DATA
The following information will be recorded from each patient’s medical records, operative notes, radiographs and photographs:
i) i) Age,
ii) Sex,
iii) Anatomic location,
iv) Size of hemangioma,
v) Complications noted at the time of consultation,
vi) Type of treatment,
vii) Time period oftreatment.
Based on type of treatment done, each patient will be assigned to different treatment groups like:
Group I: Steroidtreatment
Group II: Sclerosing agents
Group III: Surgical treatment
Group IV: Laser treatment
Group V: Combined therapy
Then follow up of the patients will be done. Based on available preoperative information and post operative follow up, treatment outcomes for each patient will be determined based on
i)Complete resolution of the tumor
ii)Recurrence of the lesion
iii)Ulceration following treatment
iv)Presence or absence of scar
v)Any cutaneous atrophy
vi)Improvement in color texture of the lesion
Results of each of these parameters will be summarized by groups.
Finally, comparison of the treatment outcomes between different groups will be analyzed by means of non parametric tests like Kruskal Wallis test or Chi-square test.
INCLUSION CRITERIA
  1. Individuals with a diagnosis of hemangioma.
  2. Location of anomalies in head, face & neck areas.
EXCLUSION CRITERIA
  1. Individuals with a diagnosis of vascular and lymphovenous malformations.
  2. Individuals with incomplete records.
  3. Location of anomalies other than cervicofacial region.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS TO BE CONDUCTED IN PATIENTS OR OTHER HUMANS
No, the study does not require any investigations or interventions to be conducted in patients or other humans.
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION :
Yes, ethical clearance letter is enclosed.
8. / LIST OF REFERENCES
  1. Achauer BM, Chang C-J, Vander Kam VM. Management of hemangioma of infancy: review of 245 patients. Plastic & Reconstructive Surgery 1997;Vol 99(5), 1301-1308
  2. Williams EF, Stanislaw P, Dupree M, Mourtzikos K, Mihm M, Shannon L. Hemangiomas in infants and children: an algorithm for intervention. Archives of Facial Plastic Surgery 2000;2:103-111
  3. Kane WJ, Morris S, Jackson IT, Woods JE. Significant hemangiomas & vascular malformations of the head & neck: clinical management and treatment outcomes. Annals of Plastic Surgery 1995;35:133-143
  4. Chen MT, Yeong EK, Horng SY. Intralesional corticosteroid therapy in proliferating head and neck hemangiomas: a review of 155 cases. Journal of Pediatric Surgery 2000;Vol 35(3):420-423
  5. Popescu V. Intratumoral ligation in the management of orofacial cavernous hemangiomas. Journal of Maxillofacial Surgery 1985;Vol 13:99-107
  6. Waner M, Suen JY, Dinehart S. Treatment of hemangiomas of the head and neck. Laryngoscope 102: October 1992;1123-1132

9. / SIGNATURE OF CANDIDATE
10. / REMARKS OF THE GUIDE:
11. / NAME AND DESIGNATION( IN BLOCK LETTERS) OF
11.1 GUIDE / DR. S.M.SHARMA
PROFESSOR AND HEAD,
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY,
A.B.SHETTY MEMORIAL INSTITUTE OF DENTAL SCIENCES, DERALAKATTE, MANGALORE- 575018.
SIGNATURE
11.2 CO-GUIDE ( if any )
SIGNATURE
11.3 HEAD OF THE DEPARTMENT / DR. S.M.SHARMA
PROFESSOR AND HEAD,
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY,
A.B.SHETTY MEMORIAL INSTITUTE OF DENTAL SCIENCES, DERALAKATTE, MANGALORE- 575018.
11.4 SIGNATURE
11.5 REMARKS OF THE CHAIRMAN & PRINCIPAL
11.6 SIGNATURE