|Year : 2021 | Volume
| Issue : 3 | Page : 205-207
A case report of anesthetic management of a large tumor of the nape of neck in a child
Jerry Joseph Joel1, Anita Shirley1, Priyanka Daniel2, Ekta Rai1
1 Department of Anaesthesia, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Anatomy, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Submission||02-Nov-2020|
|Date of Acceptance||14-Apr-2021|
|Date of Web Publication||04-Mar-2022|
Jerry Joseph Joel
Department of Anaesthesia, Christian Medical College, Vellore - 632 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Large tumors of the head-and-neck region pose a challenge for the anesthetist, as often the anatomy gets disturbed in the area leading to difficulty in the airway management. Here, we report the case of a 2-year-old child with small round cell sarcoma of the neck with a 20 cm × 30 cm mass over the nape of the neck, extending from the occipital protuberance to C7 level and from the lateral margin of one sternocleidomastoid to the other, who was posted for subtotal excision of the swelling over the occipital and posterior cervical region under general anesthesia. The airway management was sought by introducing fiberoptic bronchoscope, and an endotracheal (ET) tube insertion was attempted which failed even after multiple attempts. Hence, a laryngeal mask airway (LMA) was inserted through which bronchoscope and ET tubes (ETTs) were inserted and airway was secured. Anesthesia was maintained with isoflurane and 0.1 mg/kg of atracurium and adequate opioids were given for analgesia. Surgeons described the tumor tissue to have brain tissue like consistency which caused difficulty in catching the bleeding vessels, and hence, there was massive intraoperative blood loss. Eventually, the child recovered well in the postoperative period and was discharged after a few weeks. Through our experience, we would like to suggest that pediatric anesthesiologists plan for fiberoptic intubation through the LMA as the first intubation attempt in a child with a potentially difficult airway, using two ETT's secured through a cut ETT connector. We would also like to highlight the importance of preparedness to handle massive blood loss in a round cell sarcoma.
Keywords: Difficult airway, fiberoptic intubation, large tumor of neck, laryngeal mask airway endotracheal tube, massive blood loss, pediatric anesthetist
|How to cite this article:|
Joel JJ, Shirley A, Daniel P, Rai E. A case report of anesthetic management of a large tumor of the nape of neck in a child. CHRISMED J Health Res 2021;8:205-7
|How to cite this URL:|
Joel JJ, Shirley A, Daniel P, Rai E. A case report of anesthetic management of a large tumor of the nape of neck in a child. CHRISMED J Health Res [serial online] 2021 [cited 2022 May 28];8:205-7. Available from: https://www.cjhr.org/text.asp?2021/8/3/205/339045
| Introduction|| |
Large tumors of the head-and-neck region pose a challenge for the anesthetist, as often the anatomy gets disturbed in the area leading to difficulty in airway management. Any large tumor of the neck requires expertise and proper planning on the part of the anesthetist, to avoid damage to the already distorted anatomy. Small round cell sarcoma is a group of highly malignant and aggressive neoplasms which occurs mostly in the pediatric age group with a high risk of mortality. Chemotherapy with surgery and radiation therapy provides good cure rate. The anesthetic management of these tumors depends on the position and size of the tumors and the complexity of the surgical procedure and poses a challenge to the anesthetist.
| Case Report|| |
A 2½-year-old child presented with a painless swelling at the nape of the neck for 11 months of age. History from the parents did not reveal any airway obstructive symptoms like snoring or mouth breathing and or even frequent waking up in the night. Magnetic resonance imaging (MRI) of the neck done reported a venolymphatic malformation extending from the occipital protuberance to C7 level and from lateral margin of one sternocleidomastoid to the other in transverse dimension in the posterior part of the neck. MRI was carried out under sedation with propofol Total Intra venous anaesthesia (TIVA) and was uneventful as the tumor was very small at that time, measuring only 5 cm × 10 cm not restricting any neck movements. Owing to the small size of the tumor, sclerotherapy was attempted under general anesthesia with endotracheal (ET) intubation which was also uneventful. Later, there was a rapid increase in size of the tumor over a period of 1 month, which on examination revealed a tense swelling measuring 20 cm × 30 cm over the nape of the neck, causing inability to extend the neck. Eventually, the child was planned for a subtotal excision of the swelling over the occipital and posterior cervical region to relieve the hyperflexion and to halt further damage caused by the growth of tumors, under general anesthesia.
Preoperatively, the parents gave a history of difficulty in sleeping supine; however, the child slept comfortably on either side. There was a history of occasional snoring but otherwise no features of waking up in the night or any distress while asleep. Preoperative assessment revealed that the neck was flexed with hardly any extension but with a good mouth opening corresponding to Mallampatti Score II. Good venous access sites were noted in the dorsum and forearm of both the hands, and no sedative premedication was administered.
Anesthetic management began with adequate preoxygenation and induction with oxygen and sevoflurane [Figure 1]. Peripheral IV access was obtained through which small increments of propofol were given and the child was kept on spontaneous respiration with a nasal airway connected to the open circuit [Figure 2]. The toddler was ramped and a ring was kept under the neck to accommodate the neck swelling for positioning, to aid in the intubation [Figure 3]. Fiberoptic bronchoscope was inserted through the other nostril and the airway anatomy was found to be distorted because of the pressure effects of the swelling. With further manipulation of the bronchoscope, cords were visualized, and bronchoscope could be inserted into the vocal cords. However, the ET tube (ETT) could not be threaded even after multiple attempts. Hence, a laryngeal mask airway (LMA) was inserted through which bronchoscope and ETTs were inserted and airway was secured. Anesthesia was maintained with Isoflurane and 0.1 mg/kg of atracurium and adequate opioids were given for analgesia. The patient was then made prone, and all pressure areas were thoroughly cushioned, and surgery was commenced [Figure 4].
|Figure 2: Spontaneous respiration with a nasal airway connected to open circuit|
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|Figure 3: Child ramped and a ring kept under the neck to accommodate the neck swelling for positioning for intubation|
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|Figure 4: Patient made prone and all pressure areas thoroughly cushioned|
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Intraoperatively, there was massive blood loss of about 1.2 litre for which transfusion of packed cells and fresh plasma was done. The child remained stable for the rest of the surgery, and the intubated child was shifted to the pediatric intensive care unit for postoperative ventilation. Surgeons described the tumor tissue to have brain tissue like consistency which caused difficulty in catching the bleeding vessels leading to the massive intraoperative blood loss.
Postoperatively, elective extubation was successfully done in theater on the third postoperative day. Pathological reports of biopsy sent intraoperatively confirmed the presence of small round cell sarcoma. The child recovered well in the postoperative period and was discharged after 4 weeks when he was able to hold the neck by himself.
| Discussion|| |
Anesthetic management of a difficult infant and pediatric airway requires planning, preparation, and teamwork. LMA, light wand, and fiberoptic bronchoscope are important tools for managing the difficult pediatric airway. In our case, as the airway anatomy was distorted due to the mass and pressure effects of the tumor, it was impossible to thread the ETT over the fiberoptic bronchoscope through the vocal cords, thereby an LMA was inserted and used as a conduit for ET intubation. Intubating children with difficult airways fiberoptically, through an LMA, has gained much popularity because the LMA reliably provides a patent airway. This has been observed in children with both normal and difficult airways.,
Advantages of fibreoptically intubating through the LMA include controlled ventilation of the anesthetized patient and the ability of the LMA to serve as a conduit for fiberoptic intubation. Similar anesthetic techniques have been reported by Walker, Rowbottom et al., Silk et al., Ebata et al., and Beveridge.,,,, Greatest challenge encountered when intubating through an LMA is how to remove the LMA without dislodging the ETT from the trachea. This difficulty is unique to the pediatric anesthesiologist. Because the lengths of an age-appropriate pediatric ETT and LMA are similar, the proximal end of the ETT tends to disappear into the LMA once the ETT has passed through the vocal cords. This makes it difficult to safely remove the LMA without dislodging the ETT.,, Using 2 ETTs with a connector provided the extra length to hold the ETT in place while removing the LMA. A rather surprising and unanticipated challenge was the intra-operative bleeding that resulted in substantial hemodynamic instability, necessiting prompt fluid along as well as blood and plasma products transfusion. The peculiar thing noticed and informed by the surgeons was the brain tissue like consistency of the tumor tissue which made it extremely difficult to catch the bleeders and the eventual massive blood loss. Surgeons were able to achieve hemostasis only after excision of all the tumor tissue all along the plane.
This case report highlights the peculiar anesthetic challenges involved in the management of a child with difficult airway and the anesthetic concerns in terms of difficult intubation due to hyper flexed neck, mass effect on trachea, mild tracheomalacia, prone positioning, unusual tumor tissue characteristics, massive blood loss and transfusion, and its complications. We suggest pediatric anesthesiologists think about performing a rather atraumatic fiberoptic intubation through the LMA as his/her first intubation attempt in a child with a potentially difficult airway, using two ETT's secured through a cut ETT connector and also importantly keep in mind the specific tumor tissue features in round cell sarcoma where we need to be prepared to handle massive blood loss. The fact of the matter is that with proper planning, anticipation and adequate preparation one will be able to handle all mishaps, deal with problems and avoid complications pertaining to a child with a difficult airway, specific tumor pathology, and its anesthetic concerns.
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]