Treatment of ranula with intracystic
injection of the streptococcal preparation OK-432.
Fukase S, Ohta N, Inamura K, Aoyagi M.
Department of Otorhinolaryngology, Yamagata University School
of Medicine, Yamagata, Japan.
Intracystic injection of OK-432 was developed as a therapy for
operatively difficult lymphangioma (cystic hygroma) and is currently
becoming a treatment of first choice for this disease. We tried
this therapy in 32 patients with ranula (oral floor type in 21
cases and plunging type in 11 cases). Disappearance or marked
reduction of the lesion was observed in 31 patients (97%) who
had this therapy, and local scarring did not occur in any patient.
As side effects, local pain at the injection site and fever (37
degrees C to 39 degrees C) were observed in almost half of the
patients who had this therapy, but such problems resolved within
a few days. We treated the initial 4 cases in the hospital for
4 to 5 days, but after the safety of this method had been confirmed,
we treated the other 28 cases on an outpatient basis. Thus, we
confirmed that intracystic injection therapy with OK-432 is relatively
safe and can be used as a substitute for surgery in the treatment
of ranulas.
Cystic lymphangioma and plunging
ranula treated by OK-432 therapy: a report of two cases.
Ikarashi T, Inamura K, Kimura Y.
Department of Otolaryngology, Tsuruoka Municipal Shonai Hospital,
Japan.
Among head and neck angiotumors, cystic lymphangioma occurs in
infancy in most cases and it is rare in adulthood. Plunging ranula
is one of the diseases which need to be distinguished from lymphangioma,
though operation is the first choice therapy for both of these.
In the present study, we report on 2 cases in whom we conducted
intralesional injection of OK-432 for cervical lymphangioma and
ranula found in 20 and 35 year-old female patients. We obtained
excellent improvement. First of all, we punctured the tumors and
sucked out the liquid content as much as possible, and then used
OK-432 in the same volumes to those drawn out. No swelling was
observed in either patient after 1 month, and cysts disappeared
in CT 4 and 12 months after injection, respectively; at present,
the prognosis is satisfactory, without recurrence. The intralesional
injection of OK-432 is considered an effective method, as the
speed of complete disappearance by this therapy is high. Cosmetically
it is superb, leaving no lesions in the skin of the injection
site.
Recurrent plunging ranula treated
with OK-432.
Woo JS, Hwang SJ, Lee HM.
Department of Otorhinolaryngology and Head and Neck Surgery, Communication
Disorder Institute of the Medical Science Research Center, Korea
University College of Medicine, Seoul, Korea.
A 36-year-old man was admitted who had a 2-month history of swelling
of the right submandibular area and the right side of the mouth
floor. He had undergone operations for right plunging ranula with
a lesion on the floor of the mouth twice 7 years ago. Under fluoroscopic
guidance, the contents of the cyst were aspirated as much as possible
and injected with the same amount of OK-432 solution (Picibanil
0.1 mg; 10 ml) twice with 3-week intervals. Examination after
6 weeks showed that the cystic mass seen before therapy had disappeared
completely, and no recurrence was encountered after 1 year. We
here report a case in which a successful sclerotherapy with OK-432
for recurrent plunging ranula after surgery was performed.
Local injection of OK-432 in
the treatment of ranula: a case report.
Watanabe K, Tomiyama S, Jinnouchi K, Nakajima H, Yagi T.
Department of Otorhinolaryngology, Nippon Medical School, 1-1-5
Sendagi, Bunkyoku, Tokyo 113-8603, Japan. bxp02646@nifty.ne.jp
We treated a 57-year-old woman for ranula. After aspirating the
cyst's contents, we administered 0.1 KE/ml of OK-432 via local
injection. One month later, the cyst had still persisted, so we
repeated the procedure. After 2 weeks, the ranula began to shrink
markedly, and at 4 weeks it had almost disappeared. No recurrence
of the ranula was observed during the subsequent 1 year of follow-up.
Following each injection, the patient developed transient fever
and local swelling but no serious complications. Our experience
suggests that OK-432 injection is an effective treatment for ranula.
However, because this treatment causes the cyst to collapse rather
than disappear completely, patients should be regularly monitored
over the long term.
OK-432 injection therapy for
plunging ranula.
Muraoka M, Taniguchi T, Harada
T.
A31-year-old woman had a ranula of the right
sublingual salivaly gland for 2 years. It gradually extended into
the right parapharyngeal space and it was treated with intralesional
OK-432 injections. After aspiration of 2ml of the fluid, 2ml of
OK-432(0.5KE) was injected. A pyrexia iof 39℃ was observed over
the first 2 days and a mild fever continued for the following
4 days. She had general fatigue and local pain for the first 2
days; the pain was controlled by oral analgesics. This mild swelling
gradually settled and disappeared at 1 month post-injection. At
3 months post-injection an MRI scan confirmed resolution of the
lesion. At 1 year there was no evidence of recurrence.
Sclerotherapy for congenital
lesions in the head and neck.
Kim KH, Sung MW, Roh JL, Han MH.
Department of Otolaryngology-Head and Neck Surgery, Cancer Research
Institute, Seoul, Korea. kimkwang@plaza.snu.ac.kr
OBJECTIVES: This study retrospectively reviews the results of
sclerotherapy using several sclerosants for congenital lesions
of the head and neck. METHODS AND PATIENTS: Between May 1990 and
May 2002, patients with lymphatic malformations were treated by
sclerotherapy; 10 with bleomycin, and 25 with OK-432. OK-432 sclerotherapy
was also applied in 9 patients with plunging ranula and in 1 patient
with branchial anomaly. Percutaneous sclerotherapy with ethanolamine
oleate was used in 29 patients with venous malformations, and
28 patients with pyriform sinus fistula were treated by trichloroacetic
acid chemocauterization. RESULTS: Overall, two thirds of patients
with these lesions showed marked to complete response. One case
of mortality occurred in the bleomycin sclerotherapy group. However,
no major complications by other sclerosants were found. In lymphatic
malformations, history of excision before sclerotherapy was a
poor prognostic factor. CONCLUSION: Sclerotherapy using these
sclerosants is a safe and effective primary treatment for congenital
lesions in the head and neck.
Primary treatment of ranula
with intracystic injection of OK-432.
Roh JL.
Department of Otolaryngology-Head and Neck Surgery, Cancer Research
Institute, Chungnam National University College of Medicine, Daejeon,
Republic of Korea. rohjl@nu.ac.kr
OBJECTIVE: Although surgery is the first choice of therapy for
ranula, it was made a hypothesis that ranula can be primarily
treated with sclerotherapy from prior evidence. This study examined
the effectiveness of intracystic injection of OK-432 for treatment
of ranula. METHOD: This prospective clinical study comprised a
total of 26 patients with ranula (19 intraoral type; seven plunging
type) treated with OK-432 sclerotherapy. Aspirated mucus of ranula
was replaced with an equal volume of OK-432 solution of 0.01 mg/mL.
The size of ranula was compared before and after sclerotherapy.
RESULTS: Twenty of 26 patients (77%) showed a complete response
after sclerotherapy: higher in plunging ranula (86%) than in intraoral
ranula (74%). Rupture of ranula developed in seven of 19 patients
(37%) with intraoral ranula within a few days after injection.
The early rupture occurred more frequently in patients having
a less-than-marked response and seemed to cause an increase in
the total number of OK-432 injections: seven ruptured cases versus
12 nonruptured cases (mean 3.6 versus 1.5, P<.001). Recurrence
occurred in two patients during a median follow-up period of 12
months (range, 9-22 mo) after the last injection. There were no
major side effects, scarring, or increased morbidity to surgery
of the OK-432-injected lesions. CONCLUSION: The intracystic injection
of OK-432 is highly effective as a primary treatment modality
of ranula.
OK-432 sclerotherapy of plunging
ranula in 21 patients: it can be a substitute for surgery.
Rho MH, Kim DW, Kwon JS, Lee SW, Sung YS, Song YK, Kim MG, Kim
SG.
Department of Radiology, Masan Samsung Hospital, Sungkunkwan University
School of Medicine, Masan, Korea.
BACKGROUND AND PURPOSE: Although first-choice therapy for the
ranula is surgery, this choice presents technical difficulties
and frequent recurrences because of insufficient surgery. We evaluated
the efficacy of OK-432 sclerosis of the plunging ranula as a substitute
for surgery. METHODS: Twenty-one patients with plunging ranula
were treated with intralesional injection of OK-432. The liquid
content of the ranula was aspirated as much as possible, after
which OK-432 solution was injected in the same volumes as that
drawn out. Patients were followed on sonography or CT. RESULTS:
Seven (33.3%) patients with plunging ranulas showed total shrinkage
and resolution, and 4 (19%) patients showed near-total shrinkage
(more than 90% of the volume). Four (19%) patients revealed marked
shrinkage (more than 70% of the volume), and 3 (14.3%) patients
showed partial shrinkage (less than 70% of the volume). Three
(14.3%) patients showed recurrence after total shrinkage 1 month
after injection. The overall recurrence rate after each injection
was 47% (16 of 34 injections in 21 patients), but the recurrence
rate after the last sclerotherapy was only 14%. There were no
serious side effects except for fever lasting 2-3 days (12 patients)
and swelling (10 patients) for 3-5 days. Mild odynophagia for
1-2 days was also noted in 7 patients, and there was 1 severe
case of odynophagia. CONCLUSION: OK-432 sclerotherapy of plunging
ranula is a safe and potentially curative procedure that may be
used as a primary treatment for plunging ranula before considering
surgery.
Treatment of Ranula in Pediatric
Patients with Intralesional Injection of OK-432.
Lee HM, Lim HW, Kang HJ, Chae SW, Hwang SJ, Jung KY, Woo JS.
From the Department of Otorhinolaryngology-Head and Neck Surgery,
Korea University College of Medicine, Seoul, Korea.
OBJECTIVE:: To assess the efficacy of treatment of a ranula in
children by intralesional injection of OK-432. STUDY DESIGN::
Retrospective analysis of 13 cases. METHODS:: Review of medical
records of pediatric patients with ranula treated by OK-432 sclerotherapy
from 2002 through 2005. RESULTS:: Among 13 cases, 9 were completely
regressed by injection therapy alone. Three cases were incompletely
regressed. One case was cured by surgical excision. The follow-up
duration was 6 to 46 (mean 24.3) months. Adverse effects of OK-432
injection were tolerable, and no complication was observed. CONCLUSIONS::
On the basis of our experience, sclerotherapy with OK-432 was
a safe and effective primary treatment for a ranula in children.
Further study will be needed to conclude its long-term effectiveness.
Sclerotherapy for cystic lesions of the head and neck region.[Article in German]
Knipping S1, Goetze G.
Abstract
Cystic lesions are frequently occurring diseases of the head and neck
region. Complete surgical resection near to neurovascular structures
can be accompanied by various complications. In selected cases
intralesional injection of OK-432 could constitute an alternative. The
average success rate of sclerotherapy of lymphatic malformations is
60%. Side effects are rare. Sclerotherapy is a minimally invasive,
simple and cost-effective procedure performed without general
anaesthesia at the outpatient clinic. Nerve lesions or troublesome
scarring do not occur. In residual cases surgical excision is
realisable without any difficulty. Repeated injections of sclerotherapy
agents represent a disadvantage. Abscess formation has been observed as
a rare complication. A malignant disease has to be excluded by
cytological examination before commencing sclerotherapy. The
intracystic injection of OK-432 is an effective treatment modality for
cystic cervical lesions.
Plunging ranula: a report of
three cases and review of the literature.
Parekh D, Stewart M, Joseph C, Lawson HH: .Br J Surg. 1987
Apr;74(4):307-9.
Three cases of plunging ranula
are reported and the literature reviewed. Extravasation of saliva
from the sublingual gland due to trauma or obstruction of its
ducts appears to be the most likely cause of plunging ranula.
Available data suggest that the submandibular gland is usually
not involved, although at the time of surgery it may be extremely
difficult to exclude a submandibular origin of the cyst in the
neck. Communication between the oral and cervical components of
the plunging ranula probably occur via a hiatus in the mylohyoid
muscle. Such communication passing directly into the submandibular
compartment may simulate submandibular gland involvement. Since
1910, 139 procedures in 89 patients with plunging ranula have
been reported in the English literature. The recurrence rate was
70 per cent after incision and drainage of the cyst, 53 per cent
after marsupialization, 85 per cent after excision of the cyst
in the neck and 2 per cent after excision of the sublingual gland
via the cervical or intra-oral route. This review suggests that
excision of the sublingual gland with intra-oral drainage of the
cervical swelling appears to be the treatment of choice for the
plunging ranula.
Primary treatment of pediatric
plunging ranula with nonsurgical sclerotherapy using OK-432 (Picibanil).
Roh JL, Kim HS.
Department of Otolaryngology, Asan Medical Center, University
of Ulsan College of Medicine, 388-1, Pungnap-dong, Songpa-gu,
Seoul 138-736, Republic of Korea. rohjl@amc.seoul.kr
OBJECTIVE: Although surgery is the first choice of therapy for
plunging ranula, it is associated with technical difficulties,
morbidity and recurrence. Plunging ranula may be also primarily
treated with nonsurgical sclerotherapy, but there is little experience
in pediatric patients. We, therefore, assessed the efficacy of
OK-432 sclerotherapy for pediatric plunging ranula. METHODS: Nine
children with plunging ranula were prospectively treated with
intracystic injections of OK-432. At the outpatient clinic, the
ranula was punctured in the neck and aspirated mucus was replaced
with 0.1-0.2mg OK-432 solution. The size of the ranula was compared
before and after sclerotherapy. RESULTS: Total or nearly total
shrinkage was observed in 6 of 9 patients; marked reduction (>50%
of original size) in 2; and partial reduction (<50% of original
size) in 1. At a mean follow-up of 26 months after last sclerotherapy,
recurrence was observed in only 1 patient; this patient showed
complete response after reinjection of OK-432 solution. No significant
complications were observed, with only fever and mild local pain
observed in 4 patients for 2-4 days after treatment. CONCLUSIONS:
OK-432 sclerotherapy is safe and effective in the treatment of
pediatric plunging ranula. Sclerotherapy may become a primary
treatment modality prior to surgery.
The therapeutic effect of OK-432
(picibanil) sclerotherapy for benign neck cysts.
Kim MG, Kim SG, Lee JH, Eun YG, Yeo SG.
Department
of Otolaryngology, Masan Samsung Hospital, School of Medicine,
Sungkyunkwan University, Masan, Korea.
BACKGROUND AND OBJECTIVES: In general, benign neck cysts are treated by surgical excision. This can present technical difficulties and frequent recurrences, because of insufficient surgery. Sclerosing agents such as OK-432 have been tested for the nonsurgical treatment of these cysts. We have assessed the efficacy of OK-432 sclerotherapy for benign neck cysts. MATERIALS AND METHODS: The study group consisted of 75 patients (42 men, 33 women) diagnosed with and treated for benign neck cysts between March 2001 and December 2007 by intralesional injection of OK-432. The liquid content of each cyst was aspirated as much as possible, and the same volume of OK-432 solution was injected. Patients were assessed by ultrasonography or computerized tomography, and therapeutic outcomes and adverse effects were evaluated by patient age, sex, cyst type, and number of injections. RESULTS: Of the 75 treated patients, 31 (41.3%) showed total shrinkage, seven (9.3%) showed near-total shrinkage (>90% of cyst volume), five (6.6%) showed marked shrinkage (>70% of cyst volume), and 17 (22.7%) showed partial shrinkage (<70% of cyst volume). No response was seen in 15 patients (20%). Despite repeated sclerotherapy, eight patients (10.7%) showed recurrences. Minor adverse effects of therapy included fever, localized pain, and odynophagia but these complications spontaneously disappeared within several days. CONCLUSIONS: OK-432 sclerotherapy is a safe and effective primary alternative to surgery in patients with benign neck cysts.
Efficacy and safety of OK-432
immunotherapy of lymphatic malformations.
Smith MC, Zimmerman MB, Burke DK, Bauman NM, Sato Y, Smith RJ;
OK-432 Collaborative Study Group.
Collaborators (43)
Georgeson K, Haynes B, Joganic E, Magit A, Pransky S, Lee C, Pohlson E, Kelley P, Cryer MC, Cook S, Bauman N, Josephson G, Andrews T, Bryan S, Robie D, Manaligod J, Smith RJ, Burke D, Burrows P, Bostrom B, McDonough E, Bruegger D, Mortelliti A, Swarnkar A, Winchell K, Blei F, Milczuk H, Richardson M, Lowry L, Jacobs I, Edmonds J, Griffin S, Biavati M, Rollins N, Wassmuth Z, Derkay C, Coggsdale L, Manning S, Kerschner J, Lin R, McMurray S, McConnell K, Connor N.
Division of Otolaryngology-Head and Neck Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA. richard-smith@uiowa.edu
OBJECTIVES: To determine the efficacy and safety of the immunostimulant OK-432 (Picibanil) as a treatment option in the management of children with cervicofacial lymphatic malformations. STUDY DESIGN: A prospective, randomized, multi-institutional phase II clinical trial at 27 U.S. academic medical centers. METHODS: 182 patients with lymphatic malformations (LM) were enrolled between January 1998 and November 2004. Of the 151 patients with complete case report forms, 117 patients were randomized into immediate or delayed treatment groups; 34 patients were nonrandomized and assigned to the open-label group. Treatment consisted of a four-dose intralesional injection series of OK-432 at eight-week intervals. Patients randomized into the delayed treatment group served as observational controls for spontaneous regression. Response to therapy was measured radiographically by quantitating change in lesion size and graded as complete (90%-100%), substantial (60%-89%), intermediate (20%-59%), or none (<20%). RESULTS: Of 117 patients randomized with intent-to-treat, 68% demonstrated a complete or substantial response to OK-432 immunotherapy. Response data for macrocystic LM were higher, with a complete or substantial response in 94% of patients; 63% of patients with mixed macrocystic-microcystic LM responded to treatment; no patients with microcystic LM responded to treatment. Spontaneous resolution occurred in less than 2% of patients. Median follow-up of 2.9 years demonstrated a 9% recurrence rate. Major adverse effects related to therapy occurred in 11 patients. As compared to historical surgical data on LM, OK-432 immunotherapy is more effective (P < .001) and has a lower morbidity (P < .001). CONCLUSIONS: OK-432 immunotherapy is an effective, safe, and simple treatment option for the management of macrocystic cervicofacial LM.
Oral and plunging ranulas: What
is the most effective treatment?
Patel MR, Deal AM, Shockley WW.
Department of Otolaryngology/Head and Neck Surgery, University
of North Carolina Hospitals, Chapel Hill, 27599, USA.
OBJECTIVES/HYPOTHESIS: Preferred treatment of oral/plunging ranulas
remains controversial. We present our experience with ranulas
at the University of North Carolina (UNC) and review the literature.
METHODS: Retrospective review. From 1990 to 2007, 16 oral ranulas
and 10 plunging ranulas were treated at UNC. Combining the UNC
series with the literature identified 864 cases for review. An
online survey was conducted to identify current treatment patterns.
RESULTS: In the UNC series, procedures for oral ranulas varied
from ranula excision (50%), combined ranula and sublingual gland
excision (44%), excision of the ranula along with the sublingual
gland and submandibular gland (6%). A cervical approach was used
in nine plunging ranula cases. One case was treated transorally
with sublingual gland removal and evacuation of the ranula. Otherwise,
the plunging ranula was removed along with the sublingual gland
(20%), submandibular gland (50%), or both (20%). One hundred fifty-one
complications were identified from the literature. Recurrence
was considered a complication and was most prevalent (63%). Nonrecurrent
complications included tongue hypesthesia (26%), bleeding/hematoma
(7%), postoperative infection (3%), and Wharton's duct injury
(1%). Sublingual gland excision yielded the fewest complications
(3%). Procedures and associated complication rates were: transoral
excision of sublingual gland (3%); transoral excision of sublingual
gland and ranula (12%); marsupialization (24%); transcervical
excision of sublingual gland, submandibular gland, and ranula
(33%); OK-432 (49%); and aspiration (82%). CONCLUSIONS: Based
on our review, definitive treatment yielding lowest recurrence
and complication rates for all ranulas is transoral excision of
the ipsilateral sublingual gland with ranula evacuation.
Treatment of auricular hematoma
by OK-432.
Kubota T, Ohta N, Fukase S, Kon Y, Aoyagi M.
Department of Otolaryngology, Yamagata University School of Medicine,
Yamagata, Japan.
Abstract
OBJECTIVES: Intralesional injection therapy with OK-432 was developed
as a therapy for operatively difficult lymphangioma (cystic hygroma)
and is currently becoming a first-choice treatment for this disease.
The aim of this article was to evaluate the outcome and complications
of the treatment of patients with auricular hematoma by OK-432
therapy. STUDY DESIGN: Case series with planned data collection.
SETTING: Yamagata University School of Medicine. SUBJECTS AND
METHODS: We tried this therapy in 21 patients with auricular hematoma
between January 2001 and February 2009. We injected OK-432 solution
into the lesion with a 27-gauge nekedle to prevent the leak of
the agent out of the hematoma. We performed this treatment on
an outpatient basis without hospitalization. RESULTS: Disappearance
or marked reduction of the lesion were observed in all patients
who had this therapy, and local scarring and deformity of the
auricle did not occur in any patients. As for side effects, local
pain at the injection site and fever (37 degrees C-38 degrees
C) were observed in a few of the patients who had this therapy,
but such problems resolved within a few days. CONCLUSION: These
results may allow us to speculate that intralesional injection
therapy with OK-432 is simple, easy, safe, and effective and can
be used as a substitute for surgery in the treatment of auricular
hematoma. Copyright 2010 American Academy of Otolaryngology-Head
and Neck Surgery Foundation. Published by Mosby, Inc. All rights
reserved.
Effects and mechanism of OK-432
therapy in various neck cystic lesions.
Ohta N, Fukase S, Watanabe T, Ito T, Aoyagi M.
Department of Otolaryngology, Yamagata University School of Medicine,
Yamagata, Japan.
Abstract
Abstract Conclusion: Our results confirmed that OK-432 therapy
is simple, easy, safe, and effective and can be used as a substitute
for surgery in the treatment of benign neck cysts. In OK-432 therapy,
inflammatory cytokines may play important roles in shrinkage of
the cystic spaces. Objective: The aim of this study was to evaluate
the outcome and mechanism of action of OK-432 therapy in benign
neck cysts. Methods: We tried OK-432 therapy in 83 patients with
benign neck cysts between April 1997 and August 2009. We aspirated
as much of the fluid content of each cystic lesion as possible,
and then replaced the volume of aspirated fluid with about half
the volume of OK-432 solution. We evaluated the mechanism of actionｫ
of OK-432 in 43 of the patients. The intracystic fluid in the
cysts was aspirated before and after OK-432 therapy, and cytokine
production in each aspirate was analyzed by ELISA. Results: Disappearance
of the lesion was observed in 63 of 83 patients (76%). Marked
reduction was observed in 13 of the 83 patients (16%). Partial
reduction was observed in two patients (2%) and no response was
seen in five (6%). Local discomfort at the injection site and
low-grade fever were side effects observed in half of the patients,
but such problems resolved within a few days. No local scarring
or deformity of the injected sites occurred in any patient. We
performed OK-432 therapy on an outpatient basis without hospitalization.
Levels of various cytokines, including tumor necrosis factor,
interleukin-8, interleukin-6, interferon gamma, and vascular endothelial
growth factor, were significantly elevated in each aspirate after
OK-42 therapy.
Sclerotherapy with picibanil (OK-432)
for congenital lymphatic malformation in the head and neck.
Sung MW, Lee DW, Kim DY, Lee SJ, Hwang CH, Park SW, Kim KH.
Department of Otolaryngology-Head and Neck Surgery, Seoul National
University Hospital, 28 Yongon-dong, Chongno-gu Seoul, Korea,
110-744.
Abstract
HYPOTHESIS/OBJECTIVES: Congenital lymphatic malformations
of the head and neck (LMHN) present special challenges to the
otolaryngologist-head and neck surgeon. Recently, a number of
sclerotherapy trials have shown promising results. In this study,
we present our experiences with picibanil (OK-432) sclerotherapy
for this lesion.
STUDY DESIGN: Retrospectively review.
METHODS: We retrospectively reviewed 21 patients who have
undergone sclerotherapy with picibanil for LMHN.
RESULTS: Satisfactory response with complete or nearly
complete shrinkage of the lesions was observed in 15 cases after
repeated sclerotherapy (average, two times). We did not observe
any significant morbidity or complications in the patients treated
with picibanil. Reduction in size of the mass was achieved in
weeks to months. Some of the patients who had not had any other
previous treatment showed remarkable reductions in size even after
the first therapy. When we used picibanil sclerotherapy as a primary
treatment for the LMHN, most of our patients showed satisfactory
results regardless of the size or location of the lesions.
CONCLUSION: Given with our experience and the reports that
failure of picibanil sclerotherapy does not hinder subsequent
surgical salvage procedures, we recommend trying picibanil sclerotherapy
as a primary treatment for the LMHN and performing surgical excision
as a secondary modality if the response to the sclerotherapy is
not satisfactory.
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