Risks and complications

1. Ulceration-Epidermal atrophy

Ulceration refers to a loss of skin covering the hemangioma. The cause for this is not known. Ulceration can occur in both focal and segmental hemangiomas. In general, ulceration is extremely painful and the degree of pain seems to be out of proportion to the degree of ulceration. Ulceration usually persists for many weeks or even months.
An ulcerated hemangioma can bleed and at times these bleeds can be severe. Surgery can be used to remove a focal hemangioma and this will dramatically reduce the degree of pain experienced by the child. Hemangiomas that have ulcerated almost always leave a scar and this can be surgically corrected. Hemangiomas of the nose almost always require surgical intervention. Hemangiomas of the upper or lower lip will often require surgical correction.

2. Auditory Obstruction

Hemangiomas may obstruct the external auditory canal and cause a conductive hearing loss. If a lesion is present in or around the canal, the accumulation of debris may result in keratosis obturans

3. Airway obstruction

A hemangioma can also involve the airway and this can lead to obstruction of the child's airway. This can occur in the presence of a beard distribution segmental hemangioma or with a focal hemangioma. The early sign of this is noisy breathing. If this is suspected, the child should be seen by a specialist in this field. We usually recommend an Ear Nose and Throat Surgeon. In some cases, surgery may be necessary to overcome the obstruction.

4. Visual Obstruction

Hemangiomas of the eyelid are serious enough to warrant special consideration. The cornea of the eye is partly responsible for focusing an image on the retina of a child's eye.

The presence of a hemangioma on one or other of the eyelids can interfere with this. As the hemangioma expands, it can deform the cornea by virtue of its weight. This will cause an image to be focused on multiple plains and the result is an out of focus image. This is known as astigmatism. Astigmatism in both eyes is usually not a problem, but if it affects only one eye, the child's developing brain will ignore the out of focus eye and a "lazy" eye will develop.
This can result in blindness of that eye.

Periorbital Hemangiomas may interfere with the visual axis and partially block the vision.
This also can result in deprivation amblyopia
It is therefore imperative that the child be seen by a pediatric ophthalmologist.

These hemangiomas can be successfully removed and if this is done early enough the astigmatism will reverse.
Both Propranolol and steroid injections have also been used to treat these hemangiomas, but, in our experience, surgical resection can completely eliminate the hemangioma as well as the astigmatism (if done early).

5. Hemorrhage

Potential bleeding is one of the parents concern regarding hemangiomas. As the child grows and becomes more active, a trauma to the lesion could become a very stressful event. Spontaneous bleeding from a lesion can also occur.

Another concern is that families may live in rural areas, that a direct and immediate access to a medical center is not feasible.

6. Psychological sequelae

One of the most important complications of a noticeable facial hemangioma is the affect on the psychological development. As children grow they develop a sense of self awareness after the age of one. This is also the time that they start sensing the feelings of others.

As the disfigurement of the child has an impact to the family members, the peers and many others, there may be a negative expressional feedback to the child. Soon the child will realize that there is something different on his/her face that makes other people stare at and commend negatively.
In early childhood, the presence of the lesion will affect the educational, social, emotional and intellectual development. These facts may lead to a low self esteem, isolation and a submissive personality.
As the affected child moves from the preschool to school age years, negative attitude from other children may be physiologically disturbing.
The child is stigmatized and these stigmata of childhood years will follow the young patient throughout the course of his/her life.
It is of paramount importance to treat early lesions causing a disfigurement, which may lead to psychological sequelae.

7. Skeletal distortion

The presence of a facial hemangioma will affect the facial skeleton. The bony structures of the face grow with the lesion. The pressure applied from the hemangioma to the underlying skeleton will affect the shape, the size and the normal outline of facial bones. A great degree of distortion may develop. The bony abnormality can be the expansion of the orbit, calvarial changes, flattening of the nasal pyramid, mandibular overgrowth, midface structural changes.
Cartilaginous destruction can also occur at the nasal alae and the pinna
It is important to realize that the bony distortion will magnify the disfigurement and further more it may require multiple complicated surgical procedures to be corrected.
Early treatment of hemangiomas and prevention of skeletal distortion is very important.

8. High output cardiac failure

High-output heart failure is a condition that occurs when the cardiac output is higher than normal. There is a circulatory overload which may develop pulmonary edema, secondary to an elevated diastolic pressure in left ventricle. These patients have usually symptoms are of a heart failure. With time, this overload causes failure of the pumping activity of the heart. Cardiac output can be gradually reduced to low levels. This condition is usually seen with multiple cutaneous lesions, hepatic lesions or very large solitary hemangiomas.
This condition is a potentially lethal complication.

9. Disseminated intravascular coagulation

In this serious medical condition, the processes of coagulation and fibrinolysis are deregulated, and the result is widespread clotting with resultant bleeding. The triggering event of disseminated intravascular coagulation in cases of extended hemangiomas is a large blood clot in a rapidly growing lesion. Within this blood clot the platelets and other clotting factors are depleted.

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