The Indian Anaesthetists’ Forum

LETTERS TO EDITOR
Year
: 2017  |  Volume : 18  |  Issue : 1  |  Page : 28--30

Anesthesia management in a giant congenital undifferentiated orbital teratoma: A challenging, rare entity


Lulu Fatema Vali, Neha Tarun Gedam, Abdul Hussain Vali 
 Department of Anesthesia, Government Medical College and Super Speciality Hospital, Nagpur, Maharashtra, India

Correspondence Address:
Neha Tarun Gedam
48, Sai Kripa Society, Naendra Nagar, Nagpur - 440 015, Maharashtra
India




How to cite this article:
Vali LF, Gedam NT, Vali AH. Anesthesia management in a giant congenital undifferentiated orbital teratoma: A challenging, rare entity.Indian Anaesth Forum 2017;18:28-30


How to cite this URL:
Vali LF, Gedam NT, Vali AH. Anesthesia management in a giant congenital undifferentiated orbital teratoma: A challenging, rare entity. Indian Anaesth Forum [serial online] 2017 [cited 2020 Sep 20 ];18:28-30
Available from: http://www.theiaforum.org/text.asp?2017/18/1/28/208965


Full Text

Sir,

Immature and malignant orbital teratomas are rare. They are characteristically massive, enlarging the orbit 2 or 3 times normal, and cause severe facial deformity and disfigurement including proptosis and eyelid stretching.[1] Complication of teratoma includes cranio-orbital invasion that can be fatal if incompletely excised.[2] General anesthesia care, including tracheal intubation, is challenging in a 2-week neonate. It is even more difficult considering the presence of a huge exophytic orbital mass. An airway lesion or a difficult airway in this age group can be a nightmare for the physician managing the case.[2]

A 13-day-old female child weighing 3.2 kg, born of a full-term normal vaginal delivery presented with a large irregular swelling in the left orbit since birth. The mass looked multilobulated and was roughly 12 cm in length and extending from the orbit to the cheek, beyond the angle of mouth. It was slightly mobile and could be lifted off the face to uncover the mouth partly [Figure 1]. Feeding was almost impossible. The child had no other congenital anomalies and was breathing normally. Magnetic resonance imaging revealed a large 11 cm × 9 cm × 4 cm lobulated mixed cystic intraorbital lesion with a large exophytic component suggestive of orbital teratoma [Figure 2]. The child was posted for surgical excision of the mass.{Figure 1}{Figure 2}

The patient was premedicated with injection atropine 0.1 mg intravenous (IV) and paracetamol suppository 30 mg/kg rectally. An assistant lifted the mass off the face and flushed O2 with JR circuit near patient's mouth continuously to preoxygenate. Our concern was difficult mask ventilation as a result of the protruding orbital mass and possible difficult intubation. Goal was to maintain spontaneous ventilation until airway Was secured.[3] Whether we would get adequate mouth opening and space to introduce the laryngoscope was the big question. Mask seal was incomplete; however, the patient could be adequately ventilated with high flows of oxygen as confirmed by visible chest rise and bilateral equal breath sounds on auscultation. We decided to retain spontaneous ventilation until the airway was secured. General anesthesia was induced with sevoflurane about 8% in oxygen.[4] A direct laryngoscopy was performed with the assistant lifting the mass away from the angle of mouth. A Cormack–Lehane Grade II view was obtained. Trachea was intubated with uncuffed flexometallic endotracheal tube number 3.5 [Figure 3]. Its correct placement was confirmed with end-tidal CO2 detection and bilateral breath sounds on auscultation after which an injection atracurium 0.5 mg/kg IV was given. If we had failed in intubation, laryngeal mask airway (LMA) and other age appropriate difficult airway equipment and emergency tracheostomy preparations were kept ready as part of contingency plan.[5] Anesthesia was maintained by O2:N2O (50:50) and sevoflurane 2 minimum alveolar concentration. We were extremely vigilant for bradycardia during surgical manipulations of the orbital mass. In our case, there was no positive oculocardiac reflex.{Figure 3}

At the end of the procedure, the patient was reversed and extubated after thorough oropharyngeal suctioning. The postoperative course was uneventful.

In conclusion, difficult pediatric airway can be tackled with careful planning and anticipation. Knowledge of recent trends in anesthesia is a prerequisite for managing such cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Heran TE, Vacharajani A, Siegel MJ. Massive Congenital Orbital Teratoma. J Perinatol 2009;29:396-7.
2Aiyub S, Chan WO, Szetu J, Sullivan LJ, Pater J, Cooper P, et al. Congenital orbital teratoma. Indian J Ophthalmol 2013;61:767-9.
3Gosavi KS, Prashantha B, Kondwilkar BD, Dhende NP. Anaesthesia management in foetus-ex-fetu. Indian J of Anaesth 2013;57:195-7.
4Rath GP, Dash HH. Anaesthesia for neurosurgical procedures in paediatric patients. Indian J Anaesth 2012;56:502-10.
5Whitwell TA, Shah SP, Franchetti A, Jain A. A Case Report of Anesthetic Management in an Eight-Week-Old Infant with Trisomy 15 Presenting for Resection of Hemangiopericytoma of the Orbit 2015;6:495. doi: 10.4172/2155-6148.1000495.