Anesthetic management of a patient presenting with huge neck lymphatic cyst.

Lymphatic cyst in the cervical region presents a great challenge to the anesthesiologist. The anesthetic difficulties are because of the extension of the cyst, difficult airway, postoperative respiratory obstruction, and coexisting anomalies. The management of such patients depends on direct communication between the surgeon and anesthesiologist. We hereby present a case of a 53-year-old male presenting with lymphatic cyst of the cervicothoracic region with dysphagia and dyspnea, posted for direct laryngoscopy and biopsy under general anesthesia. Awake fiberoptic intubation was done in this patient successfully in spite of totally distorted airway anatomy.

INTRODUCTION

Perioperative management of cystic hygroma is a real challenge encountered by the anesthesiologist. Cystic hygroma is a benign tumor usually present in a neonate or in early infancy.[1] Swelling usually occurs in the neck and may involve the parotid, submandibular area, tongue, and floor of mouth. It is a common condition in the pediatric age group,[2] but very rare in adult patients. The management of cystic hygroma is a difficult situation that anesthesiologist has to confront, with regard to airway management, especially when it extends from the cervical region to the thoracic region. In this patient, huge neck swelling revealed a dilemma of difficult intubation.

CASE REPORT

A 53-year-old male weighing 83 kg presented with swelling in right side of the neck. He had 1-month history of dyspnea on exertion and dysphagia. He was posted for rigid endoscopic laryngoscopy and biopsy. The patient did not have any other comorbidities. Airway examination showed mallampati Class III and restricted lateral flexion and extension of the neck.

An awake 70° endoscopy was done in the outpatient clinic which revealed a swelling in the posterior pharyngeal wall from the level of the tip of epiglottis and was almost touching the laryngeal surface of epiglottis, more toward the right side.

Lower extent of the swelling could not be visualized. Vocal cords could not be visualized. Computed tomography (CT) scan of the neck showed well-defined nonenhancing lesion in the right half of the posterior pharyngeal wall measuring 3 cm× 6cm× 17cm extending from C1 to T3 vertebrae with pharyngeal lumen narrowing [Figure 1]. Anteriorly the lesion is abutting the right half of base of the tongue, epiglottis, and greater horn of the hyoid displacing the internal carotid artery, right subclavian artery, and internal jugular vein [Figure 2].

Figure 1

Computed tomography picture showing tumor extending from cervical to thoracic region

Figure 2

Computed tomography scan pictures showing compression at the level of oral cavity

The procedure was posted under general anesthesia. Plan for anesthesia was awake fiberoptic intubation. Monitors were attached. Premedication was done with glycopyrrolate 0.2 mg, midazolam 1 mg, fentanyl 25 μg intravenously. Transtracheal block was performed with 2 ml of 0.2% Loxicard. Awake fiberoptic intubation was performed. Distorted airway anatomy was observed. Vocal cords were pushed to the left side and the cords were only partially visible. The epiglottis was pushed to the left side and the uvula was pushed to the right side [Figure 3]. The swelling was pushing the airway structures and with difficulty, fiberoptic scopy was done and 7.5-mm oral RAE tube was inserted into the trachea. Anesthesia was deepened with propofol after confirming the correct placement of the tube with end-tidal carbon dioxide monitoring. Neuromuscular blockade was given with atracurium. After the procedure, the patient was reversed with glycopyrrolate and neostigmine and the patient was extubated fully awake.

Figure 3

Endoscopy picture showing base of tongue and uvula being displaced to the one side

The patient was posted at a later date for tumor excision. Elective tracheostomy was done and the tumor was excised by the combined effort of the ear, nose, and throat and cardiothoracic surgeons.

DISCUSSION

Cystic hygroma is a congenital tumor of lymphatic origin.[3] Lymphatic collection occurs inside the endothelial membrane.[4] Cystic hygroma presents in neonatal and early infancy and it also occasionally presents at birth.

Airway compromise can occur if the swelling is large. CT and chest X-ray are usually done to rule out intrathoracic extension. The most important step in anesthetic management of such patients is to provide safe and secure airway. A difficult airway cart should be kept ready. In patients with difficult airway, an awake intubation is often the primary approach of airway management. Our patient had the tumor extending to the mediastinum.

Awake fiberoptic scopy was difficult due to the massive swelling completely occluding the pharyngeal space. Vocal cords were visualized with difficulty as the airway anatomy was completely deranged. We were successful in passing the tube orally.

In such situations, the anesthesiologists should be prepared to tackle any emergency situation like doing an emergency cricothyrotomy in case of failed intubation.[2] Surgeon should be present if at all emergency tracheostomy is required.[5]

Another concern in our patient was mediastinal mass syndrome which can happen while anesthetizing the patient. It can occur from intraoperative to postoperative period. This occurs due to direct compression by tumor on the airway and cardiovascular structures causing acute decompensation and airway occlusion.[6] These complications are seen more with patients who are symptomatic preoperatively. These symptoms can be overcome by changing the patient's position.

Luckily, our patient never had any such complications intraoperatively or postoperatively. We were able to extubate the patient on the table and the patient recovered postoperatively without any problems.

CONCLUSION

Cystic hygroma is a rare lesion in adulthood. Our patient had symptoms of airway compromise. Proper preoperative evaluation and workup should be done in such cases. A difficult airway cart should be ready, and a surgeon should be available for an emergency tracheostomy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.