|LETTER TO EDITOR
|Year : 2019 | Volume
| Issue : 2 | Page : 106-107
Airway management of a neonate with huge teratoma of tongue and concomitant cleft palate: A challenge for the anesthesiologist
Hemlata, Reetu Verma, Ahsan Khaliq Siddiqui, Prem Raj Singh
Department of Anaesthesiology, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||28-Aug-2019|
Department of Anaesthesiology, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Hemlata, Verma R, Siddiqui AK, Singh PR. Airway management of a neonate with huge teratoma of tongue and concomitant cleft palate: A challenge for the anesthesiologist. Indian Anaesth Forum 2019;20:106-7
|How to cite this URL:|
Hemlata, Verma R, Siddiqui AK, Singh PR. Airway management of a neonate with huge teratoma of tongue and concomitant cleft palate: A challenge for the anesthesiologist. Indian Anaesth Forum [serial online] 2019 [cited 2019 Sep 22];20:106-7. Available from: http://www.theiaforum.org/text.asp?2019/20/2/106/265649
An oral teratoma arising from tongue is a rare entity and is usually associated with cleft palate., Management of airway is a big challenge in such patients. Here, we report successful airway management of a neonate with a huge lingual teratoma and concomitant cleft palate posted for excision of teratoma.
A 5-day-old, full-term male neonate weighing 3 kg presented with a huge oral mass with cleft palate. It was a large (10 cm × 10 cm × 10 cm), soft variegated mass with some solid and cystic areas arising from the left lateral part of the tongue [Figure 1]. Rest of the clinical examination and routine investigations were normal. Computed tomography scan revealed no extension in pharynx and no major vessel encasement. A difficult mask ventilation was anticipated. Face masks of various sizes, oral airways, and laryngeal mask airways (LMAs) were kept ready. We planned an inhalational induction to avoid the likelihood of apnea associated with intravenous agents. Initially, an attempt of oral endotracheal intubation was planned. Nasal intubation and surgical airway were our back-up plans. Appropriate size endotracheal tubes (ETTs) with stylets and laryngoscopes (Miller and Macintosh blades) were kept ready. Pediatric fiberoptic bronchoscope and videolaryngoscopes can been used in pediatric patients, but were unavailable., Written informed consent was obtained from his father. Perioperative monitoring included electrocardiography, noninvasive blood pressure, SpO2, capnography, and end-tidal gas concentrations. An intravenous line was secured and xylometazoline drops were put in both the nares. Inhalational induction was done using incremental doses of sevoflurane up to 8% in oxygen. The tumor was slightly displaced toward the left side manually, so that the face mask could be placed with sufficient seal all around. The mask was kept opposed around the origin of swelling using slight pressure while an assistant held the swelling with his hands. Ventilation was gently assisted using pediatric circuit (Jackson Rees). A muscle relaxant was not administered at this stage. After achieving required plane of anesthesia, direct laryngoscopy revealed the Cormack–Lehane Grade II view. Orotracheal intubation was done successfully using a 3-mm ID uncuffed ETT taking care to avoid getting impacted in the cleft palate. After confirmation of correct placement of ETT, atracurium 1.5 mg was given IV to achieve muscle relaxation. No episodes of hypoxemia, coughing, or ventilatory difficulties were encountered during the surgery. After complete excision of the mass, stay sutures were applied to tongue and were tacked to sternum to prevent tongue fall. The stay sutures were kept for 48 h postoperatively. Subsequent course of anesthesia and extubation were uneventful. No postoperative complications or airway obstruction was noted, and the patient was shifted to the ward next evening and was discharged on day-7 with advice of physiotherapy of jaw. Histopathology of excised mass revealed a mature teratoma.
|Figure 1: Giant teratoma of tongue in a neonate (a) before intubation (b) during mask ventilation (c) after intubation and (d) after extubation postsurgery|
Click here to view
Even though we did not anticipate much difficulty in direct laryngoscopy and intubation, the huge size of mass made it impractical to rely upon bag-mask ventilation as a rescue of failed intubation. Key to proper anesthetic management in such cases with limited resources is preservation of spontaneous respiration. Handling of such masses should be gentle to prevent any bleeding into the airway which can lead to catastrophic aspiration of blood. A nasopharyngeal airway can be used effectively to tide over the crisis until a permanent solution is achieved to secure the airway.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's father has given his consent for the patient's images and other clinical information to be reported in the journal. The patient's father understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chauhan DS, Guruprasad Y, Inderchand S. Congenital nasopharyngeal teratoma with a cleft palate: Case report and a 7 year follow up. J Maxillofac Oral Surg 2011;10:253-6.
Benson RE, Fabbroni G, Russell JL. A large teratoma of the hard palate: A case report. Br J Oral Maxillofac Surg 2009;47:46-9.
Xue FS, Luo MP, Xu YC, Liao X. Airway anesthesia for awake fiberoptic intubation in management of pediatric difficult airways. Paediatr Anaesth 2008;18:1264-5.
Greenland KB, Segal R, Acott C, Edwards MJ, Teoh WH, Bradley WP. Observations on the assessment and optimal use of videolaryngoscopes. Anaesth Intensive Care 2012;40:622-30.
Nemeth J, Maghraby N, Kazim S. Emergency airway management: The difficult airway. Emerg Med Clin North Am 2012;30:401-20, ix.