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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 7  |  Issue : 1  |  Page : 25-27

A neonate with large oral cavity teratoma – An anesthetic challenge


Department of Anaesthesiology, Government Sivagangai Medical College and Hospital, Sivagangai, Tamil Nadu, India

Date of Web Publication20-Jun-2019

Correspondence Address:
Dr. G Kasirajan
Department of Anaesthesiology, Government Sivagangai Medical College and Hospital, Sivagangai - 630 561, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JIHS.JIHS_17_18

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  Abstract 


An 18-day-old female baby presented with a swelling arising from the hard palate; and presenting with a difficult breast feeding and difficult airway or obstruction is a rare condition. It may range from a simple dermoid cyst to malignant neoplasms. Airway management of this baby was very difficult and quite challenging. The airway was secured with inhalation induction and spontaneous ventilation.
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Keywords: Airway, inhalation induction, neoplasm, palatal swelling


How to cite this article:
Kasirajan G. A neonate with large oral cavity teratoma – An anesthetic challenge. J Integr Health Sci 2019;7:25-7

How to cite this URL:
Kasirajan G. A neonate with large oral cavity teratoma – An anesthetic challenge. J Integr Health Sci [serial online] 2019 [cited 2019 Nov 18];7:25-7. Available from: http://www.jihs.in/text.asp?2019/7/1/25/260826




  Introduction Top


Palatal swelling presenting with a difficult airway or obstruction is a rare condition. This swelling may range from a simple dermoid cyst to malignant neoplasms.[1] Airway management in such patients, especially children, is very difficult and quite challenging.[2],[3] Inhalational induction with spontaneous ventilation is more advantageous while intubating. Here, we report one such case.


  Case Report Top


An 18 days old newborn, weighing 3 kg, presented with a swelling arising from the hard palate in the assessment clinic for excision biopsy. The swelling was said to be diagnosed antenatally and was not intervened until now. She was a full-term vaginally delivered baby. On examination, the baby was active, cry was good, and there was no respiratory distress.

On local examination, the swelling was arising from the midline of the palate and extended from the lip margin anteriorly to the soft palate posteriorly, measuring about 2.8 cm × 2.1 cm [Figure 1] and [Figure 2]. The surface of the mass was smooth and was covered with hair; it was firm in consistency and interfered with closing of the mouth; hence, there was feeding difficulty. There was no other congenital malformation. Sedative premedication was not prescribed.
Figure 1: Before intubation

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Figure 2: Magnetic resonance imaging scan

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In the operating room, two intravenous lines were secured with a 24G cannula. All the standard monitors were connected. Difficult airway cart was kept ready. Personnel for tracheostomy were kept standby. Injection atropine 0.60 μg was administered intravenously. Preoxygenation with 100% oxygen was done for 5 min. Awake oral intubation was attempted using size 0 Macintosh blade, but was unsuccessful. A second attempt was with inhalational induction and was successful using 3-mm internal diameter (ID) uncuffed endotracheal tube (ETT). The ETT was fixed at the right angle of the mouth. Bilateral air entry was checked and was found to be equal and connected to Jacks and Rees circuit. The throat was packed with a roller gauze [Figure 3]. Anesthesia was maintained with oxygen 40%, N2O 60%, sevoflurane 0.5%, and atracurium at titrated doses.
Figure 3: After intubation

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Analgesia was achieved with fentanyl 4 μg intravenously. Intraoperatively monitoring with precardial stethoscope, pulse oximeter, End tidal carbon dioxide, temperature. The surgery lasted for 45 min, and blood loss was around 20 ml [Figure 4]. The intraoperative period was uneventful. After adequate respiratory efforts, the patient was reversed with neostigmine 120 μg and atropine 60 μg. The throat pack was removed, and after thorough suctioning and full awakening, the baby was extubated. The postoperative period was also uneventful. Histopathology was confirmed to be mature teratoma. The baby was discharged on the 9th postoperative day without any untoward event [Figure 5].
Figure 4: After resection of the tumor

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Figure 5: At discharge

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  Discussion Top


Teratoma is a swelling containing elements from all the three germ cell layers. Incidence is 1 in 4000 live births with a female predominance. It arises along the midline, most common site being the sacrococcygeal region; 6-10% in the head and neck region most often in the cervical region followed by the nasopharynx and then oropharynx.[1] The differential diagnosis of oral teratoma includes dermoid cyst, hemangioma, lymphatic malformation, melanotic or pigmented neuroectodermal tumors of infancy, encephalocoele, and rhabdomyosarcoma.

Goals of management of oropharyngeal teratoma include: (a) careful assessment of airway and provision for alternative emergency surgical airway, (b) exclusion of associated congenital lesions, (c) check laryngoscopy if possible, and (d) establshment of reliable airway under inhalational induction, preferably with sevoflurane.[4]

Airway control in pediatric patients is a challenging step in anesthetic management.[2],[3],[4] In patients with difficult airway, it is wise to go for awake intubation as the primary approach for airway management. The advantages of awake intubation are preservation of normal airway tone and respiratory efforts; moving vocal cords can be better visualized.

The anatomic and maturational factors unique to the neonatal airway are important to understand in order to effectively manage the airway. Although the traditional teaching is that all neonates, especially preterm infants, are obligate nasal breathers, the majority of neonates are actually preferential nose breathers.[5] Anything that obstructs the nares can compromise the neonate's ability to breathe. The combination of a large tongue and a relatively cephalad glottis means that on laryngoscopic examination, it is more difficult to establish a direct line of vision between the mouth and the larynx; there is relatively more tissue in a smaller distance.[6] So we are avoid nasal intubation in this neonate and also unavailability of smaller size fiberoptic bronchoscope in our institution.

Infants and children generally do not cooperate for awake intubation. Hence, it is better to keep them anesthetized using an inhalational agent such as sevoflurane on spontaneous ventilation for easier intubation. The success of inhalational induction depends on ensuring adequate depth of anesthesia and maintenance of airway patency throughout the induction. Targeting an adequate plane of anesthesia without compromising spontaneous ventilation is difficult with intravenous induction agents. Sevoflurane is the inhalational agent of choice due to its rapid induction with loss of eyelash reflex in 60–90 s and rapid recovery with lower incidence of cough during induction and emergence.[7] Myocardial depression is also relatively less in sevoflurane when compared to halothane.

The expected postoperative complications include inability to tolerate extubation, laryngospasm, laryngeal edema, and postextubation croup. The incidence of postoperative croup increases with multiple attempts of intubation, increased duration of surgery, and use of bigger size ETT. Postoperative monitoring and observation is warranted.

Sen et al. recommended the use of left paraglossal laryngoscopy as a technique for intubation in infants with oral congenital teratoma.[8] However, anesthetist's experience is the prime factor in increasing the efficacy of this approach and fortunately, we have succeeded with this approach in our case.

Ramani et al. reported the successful management of a 15-month-old child with a palatal swelling. Inhalational induction and oral intubation were achieved with 3.5-mm ID ETT using a medium-sized curved laryngoscope blade.[3] Miyoshi et al. described a case in which mask ventilation and laryngoscopy were considered impossible and fiber-optic nasal intubation was successfully performed with topical anesthesia without sedation.[9] In our case, though the swelling reduced the working space for direct laryngoscopy, adequate mouth opening and the relative mobility of the swelling were a scoring point. Fiber-optic intubation was not tried as the appropriate size was not available.

Diaz et al. described nasal intubation using inhalational induction with halothane in a case of pharyngeal teratoma.[10] As halothane can cause bradycardia and arrhythmias, we used sevoflurane in our case.


  Conclusion Top


Airway management is an essential skill of anesthetists. It is important to understand the normal airway anatomy and physiology. Prompt recognition and management of the symptoms and signs of airway compromise need expertize. Always go by protocols, equipment, and techniques which are familiar. Never give a second thought to seek senior's help. Extubate only after the baby is fully awake; extubation can wait rather than reintubation.

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.



 
  References Top

1.
Laberge JM, Puligandla PS, Shaw K. Teratomas, dermoids, and other soft tissue tumors. In: Holocomb GWIII, Murphy JP, editors. Ashcraft's pediatric surgery. 5th ed. Philadelphia, PA: Saunders Elsevier; 2010; pp. 915-35.  Back to cited text no. 1
    
2.
Kundra P, Krishnan S. Airway management in children. Indian J Anaesthesiol 2005;49:300-7.  Back to cited text no. 2
    
3.
Ramani MN, Shah SK, Parikh U, Mehta P, Vakil SD. Infant with a platal swelling an anaesthetic challenge. Indian J Anaesthesiol 2002;46:217-8.  Back to cited text no. 3
    
4.
Mishra SK, Kavitha J, Kumaravel S, Lalatendu KK. Anesthestic management of a newborn for pedunculated teratoma of oral cavity. Anesth Essays Res 2010;4:124-5.  Back to cited text no. 4
  [Full text]  
5.
de Almeida VL, Alvaro RA, Haider Z, Rehan V, Nowaczyk B, Cates D, et al. The effect of nasal occlusion on the initiation of oral breathing in preterm infants. Pediatr Pulmonol 1994;18:374-8.  Back to cited text no. 5
    
6.
Miller MJ, Carlo WA, Strohl KP, Fanaroff AA, Martin RJ. Effect of maturation on oral breathing in sleeping premature infants. J Pediatr 1986;109:515-9.  Back to cited text no. 6
    
7.
Lerman J, Sikich N, Kleinman S, Yentis S. The pharmacology of sevoflurane in infants and children. Anesthesiology 1994;80:814-24.  Back to cited text no. 7
    
8.
Sen I, Kumar S, Bhardwaj N, Wig J. A left paraglossal approach for oral intubation in children scheduled for bilateral orofacial cleft reconstruction surgery – A prospective observational study. Paediatr Anaesth 2009;19:159-63.  Back to cited text no. 8
    
9.
Miyoshi E, Kitamura S, Kinouchi K, Fukumitsu K, Nagai S. Anesthetic management for newborn pharyngeal teratoma. Masui 1999;48:884-7.  Back to cited text no. 9
    
10.
Diaz JH, Stedman PM, LeTard FX. Perioperative management of newborn pharyngeal teratomas. Anesthesiology 1984;61:608-10.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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