Novel technique of inhalational induction of an infant with a large nasal mass.

Sir,

Discussed here is a case of a full-term neonate aged 1 day who was having a large sessile growth in the region of the right nares. The growth was round with a diameter of approximately 7 cm; it completely occluded the right nostril [Figure 1]. The patient was planned for a surgical excision of the growth. There was no other significant abnormality in the patient from the anesthetic point of view. The patient was identified as a case of anticipated difficult bag mask ventilation and a possible difficult intubation.

Figure 1

Patient having a large circular sessile growth in the nasal region

Taking into consideration the anticipated difficulty in airway management, an inhalational induction was considered to be the safest. Although inhalational induction with sevoflurane was considered safe, but administering inhalational agent was a challenge as the growth prevented the fitting of the facemask. Due to the poor fit of the facemask the application of positive pressure ventilation was also not possible.

Induction of anesthesia using intravenous agents was not considered safe as it may lead to rapid loss of airway tone, thereby compromising the airway patency. Besides rapid induction with intravenous agents may lead to apnea and in this particular case apnea was not at all desired (due to inability to mask ventilate the patient). Hence, inhalational induction of anesthesia was the only option left and innovation was needed to deliver the inhalational agent to the lungs.

For delivery of the inhalational agent, the anesthesia breathing circuit was primed with 8% sevoflurane. All the standard monitoring's were applied. Xylometazoline was sprayed in the left nostril. A noncuffed endotracheal tube (ETT) of internal diameter 3 mm was cut at the proximal end (end at which the male connector is attached) to a premeasured length (from the nostril to the tragus) was inserted through the left nostril [Figure 2]. The patient was preoxygenated with 100% oxygen by attaching the oxygen tubing to ETT connector. After preoxygenation, the Jackson–Rees anesthesia breathing circuit was attached to the ETT connector. The lips were occluded manually by holding them in close approximation. Now the patient was breathing 8% sevoflurane through the nasally inserted ETT. Once the patient lost consciousness the vaporizer dial was reduced to 2%. After induction of anesthesia, an intravenous cannula was inserted and secured for fluid administration. After obtaining intravenous access rigid laryngoscopy was tried using a Miller no. 0 blade and upon visualization of the glottis, a noncuffed ETT of ID 3.5 was inserted. After ensuring proper tube placement, the ETT was secured in place. Injection fentanyl citrate 2 mcg/kg and 0.1 mg/kg vecuronium bromide was given after insertion of ETT and throat pack was inserted.

Figure 2

Patient with nasally inserted endotracheal tube for administering oxygen and inhalational anesthetics

This case describes an innovative technique of inhalational induction and airway management in a neonate with large nasal mass making facemask ventilation impossible. In this case, inhalational induction of anesthesia was of utmost importance as it is the only method to ensure a maintained breathing. Inhalational induction is inherently safe as it produces slow and smooth deepening of anesthesia. If the airway muscle tone decreases and causes airway compromise then the depth of anesthesia inevitably decreases on its own.[1] Maintenance of breathing was of utmost importance as loss of breathing effort could have created a situation of cannot ventilate and cannot intubate. In our view induction of anesthesia with sevoflurane was a better option as compared to any other inhalational or intravenous agent. Some report of airway management in an adult patient with a nasal mass has been described, but to the best of authors’ knowledge, none has been described for pediatric patients, especially infants.