Endoscopic Endonasal Resection of Cavernous Hemangioma of the Palate

Objective: To report on the feasibility of endoscopic endonasal resection of a cavernous hemangioma of the palate.

Background: Palatal hemangiomas are exceedingly rare tumors representing benign proliferation of blood vessels. Despite their typically benign nature, up to 20% of hemangiomas require therapeutic intervention due to their size, location, or behavior. While many curative modalities have been reported, including microembolization, radiation, cryotherapy, sclerosing agents, steroids, and laser therapy, complete surgical excision of the lesion, usually via a transoral palatal approach, remains the most successful option. To date, endoscopic endonasal resection of a cavernous hemangioma of the palate has not been described. We aim to determine the technique and limitations of endoscopic endonasal palatal hemangioma resection to avoid an open incision.

Study Design: Retrospective case report, literature review.

Case Report: 41 yo female presented with recurrent left sided epistaxis. Oral cavity exam demonstrated a 1cm submucosal bulge on the left palate. Left nasal endoscopy showed a mild submucosal protrusion of the mass into the nasal cavity floor. CT and MRI showed a lesion in the left anterior palate with bony destruction and expansion toward the left maxillary sinus floor. Biopsy of a palatal lesion showed cavernous hemangioma.

Methods: An incision at the caudal border of the left side of the septum was made. The incision was carried laterally along the mucocutaneous junction of the nasal cavity floor and extended to the axilla of the inferior turbinate. A vertical cut at the head of the inferior turbinate was performed. The turbinate was elevated to improve exposure of the inferior meatus and nasal cavity floor. The mucosa of the septum, nasal cavity floor, and inferior meatus was then elevated en bloc to expose the palatal mass. Once the mass was well exposed in the nasal cavity, the lateral wall of the inferior meatus was drilled and the maxillary sinus was entered to expose the sinus component of the tumor. The lesion was resected with curettes and curved suctions. Forty-five and 70 -degree endoscopes were used for resection. Finally, the submucosal surface of the hard palate was exposed and freed of tumor. The palate mucosa was kept intact. For the reconstruction, a mucosal incision was made along the transition between the floor of the nasal cavity and the septum. The mucosa of the floor was placed inside the surgical cavity and the inferior meatus mucosa was used to cover the antrostomy. The inferior turbinate was repositioned and absorbable packing was placed.

Results: Complete resection of the palatal cavernous hemangioma was achieved entirely via an endoscopic endonasal approach. 1 month-post-operative nasal endoscopy showed complete mucosalization of the surgical area, inferior meatus, and inferior turbinate. There was no evidence of inferior meatus or palatal fistula.

Conclusions: Successful resection of favorable palatal hemangiomas can be achieved via an endoscopic endonasal technique, thus avoiding transpalatal approaches and risk of oronasal/oroantral fistulas. There were no complications in the immediate post-operative or short-term follow-up period.