Airway management of huge cervical teratoma.

Sir,

A four days old female child weighing 2.5 Kg presented for excision of huge cervical multiloculated teratoma (Figure 1). She also had cleft of both lips. Preanaesthetic evaluation revealed no other congenital anomaly. She had inspiratory stridor and was tachypneic due to respiratory distress. Chest was full of conducted sounds. X-ray soft tissue neck lateral view (Figure 2) showed compression of trachea. Preoperative BGA revealed SpO2 of 86%. Pre operative CT Scan for delineation of airway could not be carried out as we accepted the patient as soon as she presented. It was a major anaesthetic challenge to manage the airway of this child as whole of central neck was occupied with mass. Because of the above mentioned problems, she was accepted with high risk consent.

Figure 1

Figure 2

Though we had planned an awake intubation, still all the measures to secure a difficult airway were arranged including fibreoptic laryngoscope and LMA. After securing an intravenous line, we tried awake intubation with ETT size 2.5 mm which seemed to be safest way of securing airway in this child. Tube encountered resistance after crossing the glottis twice and had to be taken out. In third attempt, it was tried with the help of stillete and was successful with some difficulty. Extubation was uneventful, though tracheomalacia could have led to post-operative airway obstruction.Teratomas of head and neck are relatively rare (5%) and may be life threatening because of their location in the upper airway.1

Complications noted in the literature in such cases focus on the challenges of controlling the airway before tumour removal.23 Preoperative evaluation should include a chest x-ray, CT scan of neck & chest to know about invasion of the tumour. Establishment of an adequate airway has priority if respiratory distress accompanies the lesion.4 High mortality in neonates is due to inadequate airway control. In such cases preparation should be made to ensure adequate airway control immediately after delivery. If airway is secured and tumour removed in immediate postnatal period. The outcome is excellent with good survival rate.2 Intubation may be difficult due to the mass. Optimal optic control can be obtained by using a flexible endoscope with a tube passed over it.1

The alternatives for airway management could have been fibreoptic guided intubation, awake intubation and tracheostomy (not feasible in this case due to huge central mass). A large cervical mass make tracheostomy difficult if not impossible. Blind nasal may be difficult in such cases due to distorted airway anatomy of upper airway due to tumour.5 A set of ventilating bronchoscope should also be available. If complete airway obstruction is present, use of extracorporeal membrane oxygenation to continue support of the neonate should be encouraged. There can be sequelae of long term tracheal and lung compression in the form of lung hypoplasia, hypoplastic larynx and vocal cords (subglottic stenosis) and segmental tracheomalacia.2 These sequelae should be kept in mind while managing these patients. Tracheomalacia usually presents as upper airway collapse after extubation. It was not noted in our patient.

It is suggested that in such cases, a proper delineation of airway should be done preoperatively. As giant cervical teratoma is a challenging lesion for airway management in neonatal period.