|LETTER TO EDITOR
|Year : 2013 | Volume
| Issue : 1 | Page : 141-143
An unusual method of intubation in an exceptionally difficult airway in a cystic hygroma patient
Shweta R Yemul-Golhar, Surekha S Shinde, Maya A Jamkar, Kalpana V Kelkar
Department of Anaesthesia, B. J. Medical College, Pune, India
|Date of Web Publication||26-Jun-2013|
Shweta R Yemul-Golhar
505, Daisy, Silverdale Colony, B. T. Kawade Road, Ghorpadi, Pune
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Yemul-Golhar SR, Shinde SS, Jamkar MA, Kelkar KV. An unusual method of intubation in an exceptionally difficult airway in a cystic hygroma patient. Anesth Essays Res 2013;7:141-3
|How to cite this URL:|
Yemul-Golhar SR, Shinde SS, Jamkar MA, Kelkar KV. An unusual method of intubation in an exceptionally difficult airway in a cystic hygroma patient. Anesth Essays Res [serial online] 2013 [cited 2019 Nov 20];7:141-3. Available from: http://www.aeronline.org/text.asp?2013/7/1/141/114027
Cystic hygroma, also called cavernous lymphangioma, is histologically benign congenital tumor of lymphatic origin. Most are found in the neck.  These cystic lesions grow rapidly to a huge size with infiltration into the tissue planes causing dysphagia and striador. The compression and the deviation of the airway leads to significant airway problems for the anesthetist. Also, decreased oral intake leads to malnutrition and dehydration. 
We present here a case of a 1-year-old baby who came with a massive cystic hygroma, with complaints of striador and dysphagia, posted for excision. The airway as expected turned out to be difficult and various adjuncts in intubation did not help. Hence an unusual intubation technique was used which ultimately led to a successful intubation.
A 1-year-old, 5-kg female came with a huge swelling in the neck which was diagnosed to be cystic hygroma. She was posted for excision. She was an extremely malnourished and dehydrated with a huge swelling on the right side of the neck [Figure 1]. She had intraoral swellings on the right side with tongue shift to the left. CT scan showed a swelling of about 15 × 15 cms infiltrating the tissue planes and pushing the trachea to the opposite side and ensheathing the major vessels [Figure 2].
After explaining all the risk to the parents, consent for tracheotomy and postoperative ventilation was taken.
All preparation for difficult airway was done. Plan was to induce the patient on Sevoflurane and try intubation.
She was given standard premedication. After adequate preoxygenation patient was induced with Sevoflurane 0-8% ensuring that she could be ventilated. Laryngoscopy was done with Mackintosh blade no. two but even epiglottis could not be visualized. The intraoral swelling pushed the tongue to the left making it difficult to shift it with the flange. After ventilation the laryngoscopy was retried with blade no. three but still the vision was Cormack and Lehane IV. Blind intubation was tried twice but failed.
The patient was getting ventilated hence it was decided to paralyse the patient for better visualisation. Inj. Suxamethonium 2 mg/kg I.V was given. Repeat laryngoscopy failed again. Fiberoptic bronchoscope was tried; our scope could not carry such a small tube. Passing the tube alongside fiberoptic scope was tried but failed as the swelling made visualisation impossible. Finally retrograde intubation was tried.
An 18-G intracath was inserted at the cricothyroid membrane and an 18-G epidural catheter was inserted till it reached the oral cavity. A 3.5 No endotracheal tube was threaded but it would not cross the cords. A smaller tube and rotation of the tube did not work.
The patient was reventilated and a last trial of intubation alongside the epidural catheter, was tried. The tube could be inserted with guidance of the catheter. Air entry was confirmed on auscultation and capnometry [Figure 3].
Anesthesia was maintained on O 2 :N 2 O 50:50 with Isoflurane and Inj. Vecuronium as muscle relaxant.
Intraoperative course was uneventful. Blood loss was around 200 ml which was replaced. The surgeons excised as much as possible but the intraoral mass could not be excised.
At the end of the surgery it was decided to electively ventilate the patient.
The patient was extubated the next day with preparation for difficult airway. After extubation within 15 minutes the intraoral oedema increased to such an extent that the tongue protruded out. She was immediately started on Tab. Serratiopeptidase through Ryle's tube and adrenaline nebulization. Fortunately there were no problems with respiration. The swelling subsided toward the end of the day. It was noticed that the patient had developed right sided facial nerve palsy.
Rest of postoperative period was uneventful.
Cystic hygroma, also called as the cavernous hemangioma is histologically benign, congenital tumor of lymphatic origin. It is mostly found in the neck, but can also be in the axilla, mediastinum, groin and retroperitoneal. 
It presents as a congenital mass which gradually grows and produces dysphagia and striador. Most patients present in infancy. Eighteen months to 2 years is the optimum time for excision. 
The mass leads to several anesthetic problems viz. difficult ventilation and intubation, hemorrhage during the surgery and postoperative airway complications. 
We planned on Sevoflurane induction as we were not sure of the ability to ventilate. After induction it became possible to ventilate the patient. There are reports of use of other drugs like halothane,  Inj. Fentanyl and Propofol  for induction. A report shows the use of fiberoptic bronchoscope for intubation with a 5 no. tube.  Our bronchoscope, however, could not carry the 3.5 tube. Smaller bronchoscopes compound the problem as they do not have good directional and suction ability. 
Passing fiberoptic bronchoscope and then the tube alongside was tried as done for another case but visualization was not possible. 
After confirmation of the ability to ventilate suxamethonium was given to facilitate intubation as was done in a reported case but it did not help. 
Eventually it was decided to try retrograde intubation as the anatomy was felt easily though displaced to the extreme left. Unfortunately the tube threaded over the catheter could not pass below the cords. Hence laryngoscopy and intubation alongside the catheter was tried and was successful.
Retrograde intubation was tried in an infant with Goldenhar syndrome where all other methods of intubation failed. They experienced similar difficulty while passing the tube through the cords. Rotation of the tube 90˚ helped in insertion but in our patient change in direction too did not work. ,
Postextubation sudden increase in edema can make ventilation and intubation difficult. , A case reported the need for urgent tracheostomy after such edema. 
Other matters which can add to the problems are facial and hypoglossal nerve damage during dissection. This can lead to floppy tongue which can obstruct the airway. 
Aspiration of the intraoral cysts has been done but in our case the cysts were multiple and large so there were chances of incomplete aspiration with leak and pulmonary aspiration. 
Besides excision other modalities have been used like sclerotherapy, diathermy and radiotherapy which can be used on residual cysts. 
The possibility of recurrence was explained. Our patient's parents were asked to revisit after a few days for other treatment modalities for the intraoral cysts and to watch for recurrence.
Cystic hygroma is a known difficult airway case but few turn out to be so difficult that unconventional modes of intubation have to be used. The importance of proper preparation for such cases can never be emphasized more. Our aim was to bring forth another way to tackle a difficult intubation case.
| Acknowledgment|| |
Dr. Dasmit Singh. (Hon. Associate Prof. Dept of Surgery) B.J Medical College, Pune.
| References|| |
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[Figure 1], [Figure 2], [Figure 3]