بسم اللـه الرحمن الرحيم
Perioperative Airway Management of a Premature Infant With a Large Cystic Tongue Mass
Sherif El-Hadi MD Alexandria Faculty of Medicine
Case Report
A female child was delivered at 28 weeks gestation by Caesarean section to a gravida 3, para 2 mother Premature rupture of membranes and antepartum hemorrhage (placenta previa) Apgar 3 and 8 at 1 and 5 mins. Child weighed 1650 g Huge tongue swelling was immediately noted
Case Report The child was able to breathe nasally but unable to suckle. Muscle tone was normal and no other anomalies were detected clinically. Care was provided in an incubator at 29 ° C
Case Report Vital signs: HR=140, BP 86/50, RR=35, Temp= 36.5° C Oxygen saturation was continuously monitored with a pulse oximeter. Episodes of apnea and desaturation (SaO2 =85%) were noted. O2 was supplemented at 1 L/ min, to maintain SaO2 above 90%.
Case Report Laboratory values: Hb = 15.8 g/dl, Hct=54.7%, WBC: 5.5 x 103 Platelets 263 x 103 PT 13.8 s, PTT 38 s Total bilirubin: 7.8 mg/dl. Blood glucose 56 mg/dl.
Lesions of the tongue The majority of lesions found in the root of the tongue are congenital and benign, representing ectopic tissues of thyroidal, epidermal, dermal, foregut, venous, and lymphatic origin. ď Ž Primary malignancy is rare. ď Ž
Congenital Tongus Base Cyst Presenting with Laryngeal Stridor in Youth: A Case Report. Zaki Z et al. Case Report Otolaryngol. 2012; 1475
Differential Diagnosis:
Lymphangioma Haemangioma Thyroglossal duct cyst, ectopic thyroid Branchial cyst Ranula Sublingual dermoid Mucous cyst Foregut duplication cyst Rhabdomyosarcoma, neurofibroma
Therapeutic options Marsupialization under local analgesia Cyst aspiration and delayed surgery Bleomycin injection (for lymphangioma) Cyst aspiration followed by general anesthesia and excision
Airway Management: Aspiration of a total of 18 mls. of fluid from the cyst Preoxygenation Awake visualization with a Macintosh #1 blade Intubation: was successful on the second attempt after initial visualization with a styleted 2.5 mm oral tracheal tube.
Equipment
Equipment
Verification by Capnography
Anaesthesia Isoflurane 0.6-0.8% Rocuronium 1 mg (0.6mg/kg) administered IV. Total excision of the cyst was achieved in 25 minutes. Anesthesia was discontinued and spontaneous ventilation resumed.
Total excision of the Cyst
Incomplete closure to drain ooze of blood
Extubation & Postoperative Management
The mass of the tongue was significantly reduced resulting in restoration of airway integrity. Neostigmine 0.07 mg and atropine 0.1mg were administered IV after clinical partial recovery from NDMR and the patient was extubated. Patient was transferred to NICU.
Extubation & Postoperative Management
Dexmethasone 0.4 mg. was administered IV, every 8 hours. SaO2 was maintained at 98% with oxygen supplementation, which was discontinued after 24 hours. No apneic episodes on room air. Nasogastric feeding was initiated and advanced to breast-feeding within one week.
Discussion The lack of optimal prenatal care in developing countries may result potentially fatal conditions at birth Multidisciplinary approach for compromised airway experienced:
Paediatric surgeons Paediatric anesthesiologists Intensivists Radiologists.
Discussion Communication between the anesthesiologists and surgeon was crucial in decision- making Rapid and successful intubation with minimal airway trauma Repeat failed attempts correlate with:
Morbidity Poor outcomes
Discussion Radiologic imaging for airway: Magnetic resonance (MR) imaging Computed tomography (CT) scans Ultrasound surveys: used, both pre and postnatally
MR imaging of airway obstruction in infants and children. Mahboubi S, Gheyi V. Int. J Pediatr Otorhinolaryngol, 2001 Mar; 57(3): 219-27
Comprehensive prenatal ultrasound surveys help in diagnosing and guiding the management of fetal airway masses for: EXutero Intrapartum Treatment (EXIT) procedures. Ex Utero Intrapartum Treatment of Fetal Oropharyngeal cyst. Ayers AW, Pugh SK. Obstetrics and Gynecology International, 2010
EXIT Procedure
Discussion The fibreoptic bronchoscope (FOB) remains the gold standard < 2.8 mm High cost of purchase, maintenance and repair Learning curve steep Difficult navigation Blood or secretions make visualization virtually impossible
Discussion Intubating laryngeal mask airway (iLMA)as a laryngeal conduit has facilitated and improved the success rate of fiberoptic guided tracheal intubations Pediatric Airway management: current practices and future directions. Sunder RA et al.. Pediatr Anaesth. 2012 Oct: 22 (10): 1008-15
Discussion Evaluated for use in pediatric patients: ď Ž Video laryngoscopes containing fiberoptic bundles ď Ž Fiberoptic stylets with eyepieces
Video laryngoscope with D blade
Wald et al. Pediatric video laryngoscope rescue for a difficult neonatal intubation. Pediatric Anesthesia 2008
There is lack of evidence-based information in pediatric patients, particularly in neonates and infants to support the replacement of standard laryngoscopes for difficult, or even routine, intubations
Conclusions Masses or cysts of the tongue in a neonate can cause life threatening airway compromise A multidisciplinary approach and communication Highly skilled and experienced personnel familiar with the difficult airway equipment and protocols are important for a good outcome
Conclusions In experienced hands simple maneuvers can be effective in securing the airway in a rapid and atraumatic fashion. Follow up care should continue well into the postoperative period until
Extubation is deemed safe Respiratory pattern is normal Saturation is maintained on air.
Elements of Safety
Facilities
Personnel
Process