Airway First: A Retrospective Study of Tracheotomy-Primed Sclerotherapy for High-Risk Cervicofacial Venous Malformations

<b>Objectives:</b> This study assesses the efficacy of tracheotomy-primed sclerotherapy in craniofacial venous malformations (VMs), establishes evidence-based airway intervention criteria, and develops site-specific safety protocols to optimize treatment timing and safety in cases with upper airway compromise. <b>Methods:</b> We retrospectively collected the clinical data of 35 patients treated by our center between January 2008 and November 2024, who were diagnosed with cervicofacial VMs involving the upper respiratory tract. All patients underwent direct tracheotomy or tracheotomy after sclerotherapy for lesions located in the anterior cervical area. Sclerotherapy was performed under fluoroscopy or laryngoscopy after tracheotomy. <b>Results:</b> 35 patients underwent 225 sclerotherapy sessions. Nineteen patients underwent tracheotomy directly, and sixteen patients received sclerotherapy at the anterior cervical area before tracheotomy. All patients presented improvement according to magnetic resonance imaging (MRI) findings, and 94.29% (33/35) of patients reported improvement in clinical presentations. All patients experienced improvement in quality of life (QoL). No major complications occurred. Decannulation was successfully performed in all 35 patients after finishing sclerotherapy. <b>Conclusions:</b> Tracheotomy followed by sclerotherapy is safe and effective for VMs involving the upper respiratory tract. This is necessary for patients with lesions involving the laryngopharyngeal region, tongue base, and bilateral pharyngeal walls. In high-risk prophylactic tracheostomy candidates, anterior cervical sclerotherapy-tracheostomy-sclerotherapy (ACSTS) is an effective strategy for managing airway obstruction.