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LETTERS TO EDITOR
Year : 2021  |  Volume : 22  |  Issue : 1  |  Page : 109-110
 

Airway management of a child with a large hemangio-lymphangioma of the face, neck, and upper airway in stridor


Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Submission24-Oct-2020
Date of Acceptance30-Nov-2020
Date of Web Publication22-Feb-2021

Correspondence Address:
Dr. Sunil Rajan
Department of Anaesthesiology, Amrita Institute of Medical Sciences, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_168_20

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How to cite this article:
Rajan S, Subramanian A, Tosh P, Kumar N. Airway management of a child with a large hemangio-lymphangioma of the face, neck, and upper airway in stridor. Indian Anaesth Forum 2021;22:109-10

How to cite this URL:
Rajan S, Subramanian A, Tosh P, Kumar N. Airway management of a child with a large hemangio-lymphangioma of the face, neck, and upper airway in stridor. Indian Anaesth Forum [serial online] 2021 [cited 2021 May 9];22:109-10. Available from: http://www.theiaforum.org/text.asp?2021/22/1/109/309831




Sir,

Airway pathology can significantly add to the complexity of managing pediatric airway. We present the case of an 18-month-old male child with swelling of the lower face and neck beginning gradually at the age of 1 year, but rapidly increasing in size over the last 2 months, leading to stridor in supine position, and 1-week history of difficulty in feeding, as informed by the mother. He had a huge, soft swelling on the lower face involving the mandibular region, tongue, and neck [Figure 1]a. Magnetic resonance imaging showed lymphovenous malformation with multiple cystic lesions extending from the base of the tongue up to the glottic space involving both parapharyngeal spaces and extending into the mediastinum. Partial excision of these lesions was planned.
Figure 1: (a) A child with hemangio-lymphangioma, (b) videolaryngoscopic view of the glottis after resection of lesions

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Prior to surgery, the child developed acute nocturnal respiratory distress. As emergency tracheostomy would not be possible due to the presence of the mass in front of the neck, orotracheal intubation was planned. In the operation theatre the child was placed supine. After placing pulse oximeter, electrocardiogram, and noninvasive blood pressure monitors, he was preoxygenated with 100% oxygen via facemask with a Guedel oral airway. Mask ventilation remained possible during induction with 8% sevoflurane with regular capnography. No relaxant was used. Initial laryngoscopy attempts with C-MAC™ videolaryngoscope using pediatric D blade failed to identify glottic structures. Nasal fiberoptic bronchoscope (FOB)-assisted intubation also failed due to the same reason. The base of the tongue and pharynx was studded with multiple lesions and the epiglottis was unidentifiable. As the child started to desaturate, an I-gel® (size 1.5) was inserted and satisfactory ventilation was established. Through the I-gel, FOB was passed and on entering the trachea, a preloaded 4.0-mm-internal diameter endotracheal tube was railroaded and fixed. The child was ventilated overnight.

The following day, partial excision was done through external and intraoral approaches. Tracheostomy was performed as the floor of the mouth, oropharynx, and epiglottis remained involved with the multiple cystic lesions, rendering airway obstruction likely. He underwent subsequent serial excision of the lesions on three sittings. [Figure 1]b shows videolaryngoscopic view of the glottis after the third resection. Percutaneous endoscopic gastrostomy was done for feeding. The child continues to have tracheostomy and has no respiratory distress.

Lymphangiomas are benign tumors characterized by proliferation of lymphatic vessels. Nearly 90% of tumors present by 2 years of age.[1] Oral lesions may interfere with breathing, especially during sleep, and may result in life-threatening upper airway obstruction. Typical tumors present with a white pebbly surface and resemble a cluster of translucent vesicles which appear as nodule or masses. Surgical resection is the treatment of choice and requires skilled airway management, with potential need for surgical airway. The usefulness of I-gel as a conduit for intubation is known.[2],[3],[4] However, we preferred to utilize FOB assistance to ensure accurate endotracheal tube placement in light of the lower success rate associated with blind intubation through smaller I-gels, size 1, 1.5, and 2.[5] This case stresses the importance of placement of a supraglottic airway device when FOB-assisted intubation fails in a patient with difficult airway, as it provides a reliable conduit for FOB in such situations which could be lifesaving.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rathan JJ, Vardhan BG, Muthu MS, Saraswathy K, Venkatachalapathy NS. Oral lymphangioma: A case report. J Indian Soc Pedod Prev Dent 2005;23:185-9.  Back to cited text no. 1
    
2.
Choudhary N, Kumar A, Kohli A, Wadhawan S, Bhadoria P. I-gel as an intubation conduit: Comparison of three different types of endotracheal tubes. Indian J Anaesth 2019;63:218-24.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Michalek P, Donaldson W, Graham C, Hinds JD. A comparison of the I-gel supraglottic airway as a conduit for tracheal intubation with the intubating laryngeal mask airway: A manikin study. Resuscitation 2010;81:74-7.  Back to cited text no. 3
    
4.
Choi HY, Kim W, Jang YS, Kang GH, Kim JG, Kim H. Comparison of i-Gel as a Conduit for Intubation between under Fiberoptic Guidance and Blind Endotracheal Intubation during Cardiopulmonary Resuscitation: A Randomized Simulation Study. Emerg Med Int. 2019;31:8913093.  Back to cited text no. 4
    
5.
Andrés ZB, Olga GS, Elmer GR, Guillermo GC, Cesar AR, Santiago MR, et al. Tracheal intubation with I-gel supraglottic device in pediatric patients: a prospective case series. Colombian J Anesthesiol 2018;46:37-41.  Back to cited text no. 5
    


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