The Role of Propranolol in the Treatment of Subglottic Hemangioma: Case Report and Review of the Literature

A full-term 36 day old female was brought to the emergency room by her mother who reported 6 days of progressive stridor. Patient had been previously seen by the primary care physician who also noted the noisy breathing and elected close follow-up. In the interim the patient's mother noted that patient was choking more, having decreased oral intake, and decreased wet diapers. Mom also noted some purple discoloration to the lips when she observed her child having difficulty breathing. Mom denied other symptoms of upper respiratory illness or sweating during feeds, but did mention that the child's noisy breathing was most notable when crying or agitated and improved when placed prone or over mother's shoulder. During Otolaryngology consultation, fiberoptic laryngoscopy was concerning for laryngomalacia. The subglottis was not clearly visualized. The patient was then admitted to the hospital for continued observation where symptoms progressed with desaturations, increased work of breathing with retractions, nasal flaring, and a “barking” cough despite IV steroids and multiple doses of racemic epinephrine. She was then transferred to the intensive care unit and operative laryngoscopy and bronchoscopy were performed for complete airway assessment. The subglottis was found to be 90% obstructed by a soft, vascular appearing submucosal lesion consistent with a hemangioma. With a single isolated lesion, further diagnostic imaging studies were not indicated and corticosteroids were injected intralesionally and propranolol therapy was initiated. Propranolol was titrated to a weight-based dosage of 2 mg/kg/day divided three times daily and continued to approximately 18 months of age. It was well tolerated without significant adverse events.