Sclerotherapy in Head and Neck Vascular Malformations: A Contemporary Review of Agents, Indications, and Outcomes

Sclerotherapy induces endothelial injury, thrombosis, and fibrosis, thereby reducing lesion volume and symptoms. 3A wide spectrum of agents-including ethanol, bleomycin, sodium tetradecyl sulfate (STS), polidocanol, and ethanolamine oleate-has been employed, each with distinct pharmacodynamics, efficacy, and safety profiles. 6Reported response rates range from 60% to >90%, with foam-based sclerotherapy exceeding 90% and improving intralesional distribution. 9espite these advances, comparative studies have not identified a consistently superior sclerosant, with outcomes largely influenced by lesion-specific factors such as anatomical location, flow dynamics, and cystic architecture. 6Meta-analytic data suggest that sclerotherapy, surgery, and combined approaches may yield comparable results, underscoring the importance of individualized, multidisciplinary management. 7Combined strategies integrating surgical resection with adjunctive sclerotherapy have demonstrated improved functional and esthetic outcomes in complex cases. 10Nevertheless, sclerotherapy is not devoid of complications, with major adverse events reported in 10%-15% of cases, including tissue necrosis, nerve injury, and airway compromise. 11These findings IntroductIonVascular anomalies of the head and neck represent heterogeneous congenit al disorder s arising f rom ab errant vascular morphogenesis, characterized by a persistent, noninvoluting course. 1 Nearly 50-60% occur within the craniofacial region, posing significant challenges in oral and maxillofacial practice. 2Vascular malformations predominate, being present at birth and growing proportionally throughout life. 3Venous malformations are most frequent (approximately 70-75%), with a prevalence of 1 in 5,000-10,000 and up to 40% localized to the head and neck. 4Lymphatic malformations (LMs) demonstrate a strong predilection for this region (≈75%), typically diagnosed by 2 years of age, with an incidence of 1.2-2.8%and with 50%-60% evident at birth. 5 These lesions often involve the neck, tongue, and oral cavity, producing airway, swallowing, and speech compromise. 6Arteriovenous malformations, though less common, represent high-flow lesions with aggressive clinical behavior, progressive enlargement, hemorrhage, and high recurrence following incomplete treatment. 4Their chronic course, with <5% spontaneous regression, necessitates active intervention in most cases. 7The ISSVA classification provides a standardized framework to distinguish malformations from vascular tumors and categorize lesions by flow dynamics. 1ow-flow malformations, including venous and lymphatic t yp es, are most fre quently encountere d, presenting as compressible, nonpulsatile swellings with progressive enlargement and deformity. 6Their natural history involves gradual progression with episodic exacerbations triggered by trauma, infection, or hormonal influences, leading to pain, bleeding, and airway compromise. 7Historically, surgical excision was the primary modality, but its role in the head and neck is limited by incomplete resection, recurrence, and risk to adjacent neurovascular structures. 5Minimally invasive techniques, particularly sclerotherapy, have gained prominence.