Abstract
BACKGROUND: Infantile hemangiomas (IH) are the most common tumors in infancy and childhood. They are characterized by a fast proliferation phase followed by gradual involution. While most IHs follow a predictable course, those involving the parotid gland pose unique diagnostic and therapeutic challenges due to their location and potential for functional impairment. This case illustrates an unusual example of unilateral parotid hemangioma with prolonged growth, requiring alternative management strategies. CASE PRESENTATION: A two-month-old girl presented with a large unilateral parotid hemangioma, first noted on the 15th day of life, which had been rapidly increasing in size. Oral propranolol was initially prescribed, but treatment was not started by the parents, and the patient was lost to follow-up. At 3.5 months of age, the patient underwent an unplanned cosmetic surgical excision at a rural hospital, which resulted in facial nerve paresis and functional facial asymmetry. She re-presented at 7 months with a markedly enlarged lesion. Propranolol (3 mg/kg/day) was reinitiated; however, despite dose escalation, the hemangioma remained unresponsive. Systemic corticosteroids (prednisolone, 1-3 mg/kg/day) at 8 months were added, but the lesion continued to progress. At 9 months of age, metronomic chemotherapy with vinblastine (1 mg/m² IV every 3 days) and cyclophosphamide (50 mg/m² orally for 10 days) was introduced under clinical supervision. This combination resulted in significant tumor regression, as confirmed by serial imaging and clinical examination. CONCLUSION: This case reflects the challenges of managing IHs that do not respond to standard treatment guidelines. Early surgical intervention is contraindicated when other alternative medical treatment methods are available. Otherwise, it might result in significant complications, highlighting the importance of conservative management and adherence to treatment protocols. Metronomic chemotherapy has shown to be a useful option for patients who do not respond to standard beta-blockers and corticosteroids.