JSM Clinical Case Reports
Central
Clinical Image
Massive Cervicofacial
Arteriovenous Malformation
1
2
Yew Toong Liew *, Elizabeth Lim and Prepageran N
3
Department of Otorhinolaryngology, University Malaya, Malaysia
CLINICAL IMAGE
A 22 year old gentleman presented with right neck swelling
since 6 months of age. It progressively enlarged until it involved
the right face. There were no compressive symptoms, bleeding
or cardiac symptoms. There was no trauma. Clinically, there was
a huge 20 x 20 cm painless swelling situated at the upper part of
right neck that extended into right parotid region. Anteriorly, it
extended into submandibular region; posteriorly into posterior
triangle of neck, and inferiorly until level III limit. Palpable
thrill and audible bruit were present (Figure 1). Oral cavity
examination was normal. CT angiography of neck showed huge
Arteriovenous Malformation (AVM) in right infratemporal fossa
and parapharyngeal space (Figure 2). Diagnostic angiography
showed extensive right facial arteriovenous malformation with
main feeders from right maxillary artery of external carotid artery
and ophthalmic branch of right internal carotid artery (Figure 3).
There were also contributions from left internal and external
carotid artery (Figure 4). Clinically, he was characterized under
stage II according to Schobinger classification where he had
audible pulsation and bruit [1]. Arteriovenous malformations
are fast-flow vascular lesions composed of abnormal arterial
and venous vessels connected directly to one another without
an intervening capillary bed. The pathogenesis of AVMs is not
well understood. It is likely that their development is related to
mutations in genes that encode for proteins that are essential for
normal vascular development [2]. Extracranial arteriovenous
malformations (AVM) of the head and neck are rare conditions.
Most frequently, they involve the auricle [2]. Extensive case of
*Corresponding author
Liew Yew Toong, Department of Otorhinolaryngology,
Queen Elizabeth Hospital, 88300 Kota Kinabalu Sabah,
Malaysia, Fax: +6(0)5-4957036; Email:
Submitted: 20 October 2014
Accepted: 30 October 2014
Published: 31 October 2014
Copyright
© 2014 Liew et al.
OPEN ACCESS
Figure 2 Coronal view of Computed Tomography of brain and neck
showing extensive vascular malformation at right infratemporal and
parapharyngeal space.
Figure 3 Angiography showing massive AVM with feding vessels from
right ophthalmic and internal maxillary artery.
Figure 1 Lateral view of the huge right cervical swelling.
maxillofacial AVM could lead to disfigurement, facial dysfunction
and recurrent episodes of life-threatening bleeding and high
output cardiac failure. Magnetic Resonance Imaging (MRI)
and angiography procedures represent the “gold-standard” to
evaluate the nature and extent of the AVM lesions [3]. Current
treatment concepts include preoperative angiography with
super-selective embolization followed by resection of the
lesion within a few days [4]. In our case, the patient preferred
conservative ‘watch and wait’ policy rather than treatment
options such as embolization or surgical excision. Embolisation
Cite this article: Liew YT, Lim E, Prepageran N (2014) Massive Cervicofacial Arteriovenous Malformation. JSM Clin Case Rep 2(6): 1067.
Liew et al. (2014)
Email:
Central
trismus, change of speech, cranial nerves palsy with severe facial
disfigurement, or risk of death due to uncontrollable bleeding
intra-operatively. At his young age, any complications that occur
will hamper him from thriving in the competitive society. As long
as he is under strict follow up, any complications from the lesion
can be detected earlier and acted upon timely. The success of
treatment should be from the patient’s point of view rather than
the doctors’.
REFERENCES
Figure 4 Angiography shows contribution from left internal carotid
artery.
is difficult in this situation as there are multiple feeder arteries
from both internal and external carotid arteries. Embolization
carries risks of blindness, stroke while surgical excision will
involve large defects in head and neck region. Even with advances
in plastic reconstruction, function of facial structures may not
be as good. He might end up with multiple morbidities such as
1. Schobinger RA. [Diagnostic and therapeutic possibilities in peripheral
angiodysplasias]. Helv Chir Acta. 1971; 38: 213-220.
2. Kohout MP, Hansen M, Pribaz JJ, Mulliken JB. Arteriovenous
malformations of the head and neck: natural history and management.
Plast Reconstr Surg. 1998; 102: 643-654.
3. Kang GC, Song C. Forty-one cervicofacial vascular anomalies and
their surgical treatment--retrospection and review. Ann Acad Med
Singapore. 2008; 37: 165-179.
4. Gómez E, González T, Arias J, Lasaletta L. Three-dimensional
reconstruction after removal of zygomatic intraosseous hemangioma.
Oral Maxillofac Surg. 2008; 12: 159-162.
Cite this article
Liew YT, Lim E, Prepageran N (2014) Massive Cervicofacial Arteriovenous Malformation. JSM Clin Case Rep 2(6): 1067.
JSM Clin Case Rep 2(6): 1067 (2014)
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