title: Open airway surgery for subglottic hemangioma in the era of propranolol: Is it still indicated?
abstract: OBJECTIVE
  With the emergence of propranolol as the primary treatment for hemangiomas the indications for surgical intervention have been greatly reduced. There remains a role for surgical management in those patients who fail medical therapy, particularly for hemangiomas involving the airway. Detailed is our experience with subglottic hemangiomas, including three patients who failed propranolol treatment and were successfully treated with surgical excision and single stage laryngotracheoplasty (LTP) with thyroid ala graft.
  
  
  METHODS
  Retrospective case series (level of evidence: 4).
  
  
  RESULTS
  Six patients were treated with propranolol for subglottic hemangiomas over a 6 year period (2008-2014). Three patients responded to propranolol therapy and required no adjunctive surgical procedures. Three patients failed propranolol treatment, and required open resection of their subglottic hemangiomas and thyroid ala graft placement. Indications for resection were complete lack of response to propranolol in one patient, and initial response to propranolol with subsequent regrowth in the other two patients. All three patients were treated with submucosal extirpation of their hemangioma and single stage LTP; hemangioma was confirmed in all cases by positive GLUT-1 staining. All three surgical patients were successfully extubated post-operatively and none had hemangioma regrowth.
  
  
  CONCLUSIONS
  Fifty percent of patients in our series did not have long-term response to propranolol for subglottic hemangioma, highlighting the importance of close follow-up. When identified early, subglottic hemangiomas refractory to propranolol treatment can be successfully addressed with single stage LTP and tracheotomy can be avoided.
authors.affiliation: Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA. Electronic address: Bianca.siegel@chp.edu.
authors.forename: Bianca
authors.initials: B
authors.lastname: Siegel
authors.affiliation: Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.
authors.forename: Deepak
authors.initials: D
authors.lastname: Mehta
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage / Q000009:adverse effects*; D002675:Child, Preschool; D005260:Female; D006391:Hemangioma / Q000628:therapy*; D006801:Humans; D007822:Laryngeal Neoplasms / Q000628:therapy*; D058753:Laryngoplasty; D011433:Propranolol / Q000008:administration & dosage / Q000009:adverse effects*; D012189:Retrospective Studies; D013957:Thyroid Cartilage / Q000637:transplantation; D014132:Trachea / Q000601:surgery*; D017211:Treatment Failure
chemical_list: D000319:Adrenergic beta-Antagonists; D011433:Propranolol
keywords: Airway reconstruction; Propanolol; Subglottic hemangioma