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LETTERS TO EDITOR
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 74-75
 

Endotracheal intubation in a case of huge parotid tumor–A Challenge


1 Department of Anaesthesiology, AIIMS, Patna, Bihar, India
2 Department of Anaesthesiology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

Date of Submission16-Jul-2019
Date of Acceptance24-Aug-2019
Date of Web Publication13-Feb-2020

Correspondence Address:
Dr. Mumtaz Hussain
Department of Anaesthesia, Indira Gandhi Institute of Medical Sciences, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_51_19

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How to cite this article:
Kumar R, Kumar P, Hussain M, Kumar R. Endotracheal intubation in a case of huge parotid tumor–A Challenge. Indian Anaesth Forum 2020;21:74-5

How to cite this URL:
Kumar R, Kumar P, Hussain M, Kumar R. Endotracheal intubation in a case of huge parotid tumor–A Challenge. Indian Anaesth Forum [serial online] 2020 [cited 2020 Apr 7];21:74-5. Available from: http://www.theiaforum.org/text.asp?2020/21/1/74/278183




Sir,

Pleomorphic adenoma is the most common salivary gland tumor in an adult. It can affect any age group but most common in between the fifth and sixth decades of life.[1] We present a case of anesthetic management of a huge parotid mass.

A 65-year-old man weighing 70 kg was presented with complaints of swelling on the right side of the neck for the past 7 years. On examination, the giant swelling with ulceration on margin was present right side of the neck [Figure 1]. Computed tomographic scan showed a huge mass arising from the right side of parotid gland. He was posted for excision of the neck swelling. On preanesthetic evaluation, mouth opening was adequate with Mallampatti grade 2 and limited neck flexion. The trachea was shifted slightly to the right side. His hemoglobin was 9 gm/dl, and other investigations were within normal limit. Informed written consent was taken and difficult airway cart was kept ready.
Figure 1: Large parotid mass on the right side of neck

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In the operation room, baseline monitoring included electrocardiography, noninvasive blood pressure, and pulse oximetry. Intravenous accesses with two 18G cannulas were established. The patient was premedicated with glycopyrrolate 0.2 mg and midazolam 1 mg. After preoxygenation, he received fentanyl 2 μg/kg and propofol 60 mg and sevoflurane was gradually increased. Bag and mask ventilation was possible when the swelling was supported to put head midline with the help of wrapped cloth below the swelling and mass was supported below the wrapped cloth against gravity by another anesthesiologist. Laryngoscopy was done after giving intravenous succinylcholine 100 mg. Cormack and Lehane score 2B was viewed on laryngoscopy using MacCoy blade. Neck mass was supported against gravity during laryngoscopy by another anesthesiologist. The trachea was intubated with an 8-mm internal diameter cuffed flexometallic endotracheal tube with the guidance of gum elastic Bougie. After intubation, nondepolarizing muscle relaxant vecuronium was given. Anesthesia was maintained on oxygen, nitrous oxide, isoflurane, and intermittent boluses of injection fentanyl and injection vecuronium. Central venous line and left radial line were also secured before surgery. The total duration of surgery was 5 h and approximate blood loss was 1000 ml. He received 3 L of crystalloid and 3 units of a packed red cell. Surgery underwent uneventful. The trachea was extubated and shifted to the intensive care unit. The rest hospital stay was unremarkable.

In this case, mouth opening was normal and Mallampatti grade 2, but difficult mask ventilation during induction due to large parotid mass causes tracheal compression and pushes the trachea from midline. Lifting of neck mass against gravity has been reported in the airway management of thyroid mass, but has not been reported in the airway management of huge parotid mass. Chandrashekharappa et al. have successfully managed a similar case of huge parotid mass.[2] Memon and Ashraf have done endotracheal intubation using lifting large thyroid mass against gravity in an adult patient.[3] Jain and Varshney have intubated a case of huge neck teratoma in a child by holding the mass by another anesthesiologist during laryngoscopy.[4] Other authors have also managed a case of huge swelling in the neck by supporting the lateral margins of the swelling and lift the swelling against the gravity.[5] The imaging study should be assessed for tracheal deviation and tracheal compression during preoperative evaluation. We conclude that antigravity technique can be used to ease the intubation in a huge parotid mass.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ellis GL, Auclair PL, editors. Atlas of tumor pathology. Tumours of the salivary glands. Washington, DC: Armed Forces institute of Pathology; 1995. 39-41.  Back to cited text no. 1
    
2.
Chandrashekharappa K, Ravindra CG, Kumara AB. Anesthetic management of huge parotid tumor: A rare case. J Evolut Med Dent Sci 2014;3:1240-4.  Back to cited text no. 2
    
3.
Memon MI, Ashraf M. Antigravity lift technique is helpful in difficult intubation in patients with large goiter. Anaesth Pain Int Care 2009;13:78-80.  Back to cited text no. 3
    
4.
Jain G, Varshney R. Anaesthetic challenges in a patient presenting with huge neck teratoma. Saudi J Anaesth 2013;7:210-2.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Chopra V, Mehta N, Dar MR. Securing a difficult airway: Tracheal intubation achieved after deliberate placement of an endotracheal tube in esophagus: A New approach. Anesth Essays Res 2017;11:1084-7.  Back to cited text no. 5
[PUBMED]  [Full text]  


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