|Year : 2012 | Volume
| Issue : 1 | Page : 105-107
Anesthetic management of congenital epulis in neonate
Rohith Krishna, Thrivikram Shenoy, Madagondapalli Srinivasan Nataraj
Department of Anaesthesiology, Kasturba Medical College, Manipal University, Manipal, India
|Date of Web Publication||14-Nov-2012|
Department of Anaesthesiology, Kasturba Medical College, Manipal University, Manipal - 576 104
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The most common cause of difficult intubation in pediatrics is due to congenital anomalies of airway. We report a case of neonate with congenital epulis (CE) who presented with a difficult airway. A 7-day old neonate weighted 3.2 kg with a large mass occupying the oral cavity that was diagnosed as congenital epulis was scheduled for excision biopsy. The mass was large, mobile, and moving in and out with no clear pedicle. An intravenous line was inserted and secured. The airway was then assessed while the patient was awake and an assistant displaced the mass and a laryngoscope was placed to visualize the larynx easily. After preoxygenation, inhalation induction of anesthesia was accomplished using sevoflurane in oxygen. Endotracheal intubation was performed with conventional laryngoscopy. The baby made uneventful recovery after the surgical procedure. In conclusion, epulis presents a real challenge to anesthesiologists. It can be excised either under local or general anesthesia, depending on the size of its pedicle. If done under general anesthesia, assessment of the airway is mandatory for better airway management and safe endotracheal intubation.
Keywords: Congenital epulis, difficult airway, neonate
|How to cite this article:|
Krishna R, Shenoy T, Nataraj MS. Anesthetic management of congenital epulis in neonate. Anesth Essays Res 2012;6:105-7
| Introduction|| |
The congenital epulis is a benign tumor arising from the alveolar ridges of newborns and composed of nests of cells with granular cytoplasm set in a prominent vasculature.  Neumann is credited in documenting the first case of CE.  Since then, multiple cases have been reported, primarily in the pathologic, dental, and otolaryngologic literature. Surgical removal of the tumor is advocated as the treatment of choice.  In our literature search, we could find only three articles describing the anaesthetic management of a neonate posted for excision biopsy of CE. We describe here the anaesthetic management of a neonate posted for excision of CE.
| Case Report|| |
A 7-day old neonate weighted 3.2 kg who had a large mass occupying the oral cavity was scheduled for excision biopsy. The primary diagnosis was congenital epulis. The preoperative investigations were all within normal limits and there were no other congenital anomalies. The general appearance of the neonate represented a true challenge for the anesthesiologist [Figure 1], [Figure 2].
On examination it was noticed that the mass was around 4 cm in length and 6 cm in breath, but the mass was mobile and moving in and out with no clear pedicle. Hence, it was decided to take up the neonate for excision of CE under general anesthesia. A 24 gauge intravenous line was secured and intravenous fluid 2% dextrose in Ringer's lactate was started at the rate of 20 mL/h to make up for the deficits. Boluses of Ringer's lactate were given to replace the blood loss that was about 25 mL. Before inducing, awake laryngoscopy was done with No. 1 Miller's straight blade with an assistant displacing the mass out, we were able to visualize epiglottis and posterior part of the cords. After preoxygenation, inhalation induction of anesthesia was accomplished using sevoflurane 6% in oxygen [Figure 3]. Once the neonate was induced manual mask ventilation was performed easily that confirmed a patent airway. Fentanyl 7 μg and inj atracurium 2 mg were given intravenously, and ventilation assisted for 3 min. We were able to successfully intubate the neonate with a 3.5 mm uncuffed endotracheal tube at first attempt using Miller's No 1 straight blade [Figure 4]. The maintenance of anesthesia was with oxygen, nitrous oxide, and sevoflurane to achieve a MAC of one. After completion of surgery the trachea was extubated while the baby was full awake after reversal of muscle relaxant with neostigmine and atropine.
| Discussion|| |
The causes of difficult airway in children are quite different from that of adults. It ranges from congenital to acquired causes. Examples of congenital abnormalities include laryngomalacia, hemangiomas, vascular ring, and hypoplastic mandible. Epulis is another rare congenital abnormality.  The epulides are similar to gingival hyperplasia in appearance and are usually confined to one or two sites at the gum margin. They are slow growing, firm, and generally covered by intact epithelium. These are classified as fibrous epulides or ossifying epulides depending on the presence or absence of bone. These are much more locally invasive and virtually always invade bone although they do not metastasize. Congenital epulis is a rare lesion of newborn also known as Neumann's tumor, which is benign in nature. The appearance of the lesion is most common in maxillary alveolar ridge than mandibular with predominance in females than in males.  Surgical removal is the treatment of choice. 
Anaesthesia for excision of epulis could be either general or local. Some cases were reported in the literatures where epulis was excised successfully under local anesthesia. , Other reports stated that epulis was excised under general anesthesia. ,, In this case report, we are describing excision of CE under general anesthesia. Airway management in these children can pose real challenge and anesthesiologist should have skills and knowledge to face the challenge posed in these situations. We were confident of intubating the trachea in this child as the mass was mobile and on doing awake laryngoscopy, we were able to visualize the posterior part of the cords. Mask ventilation was easy and hence the child was paralyzed. But if a child presents with a firm CE that is not mobile we may need to be very cautious and keep Laryngeal Mask Airway (LMA) and fiber optic bronchoscope ready if required. In case of emergency surgical tracheostomy and cannula cricothyroidotomy may be needed.  Even though awake intubation in neonates is associated with raised intracranial pressure,  in situations like this it still has a role.
In conclusion, epulis presents a real challenge to anesthesiologists. It can be excised either under local or general anesthesia, depending on the size of its pedicle. If under general anesthesia, assessment of the airway is mandatory for better airway control and safe endotracheal intubation.
| Acknowledgment|| |
The Author would like to thank the patient for providing consent to use her photograph in this article.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]