Anesthesia: Essays and Researches

LETTER TO EDITOR
Year
: 2010  |  Volume : 4  |  Issue : 2  |  Page : 124--125

Anesthestic management of a newborn for pedunculated teratoma of oral cavity


Sandeep Kumar Mishra1, J Kavitha1, S Kumaravel2, K Kumar Lalatendu2,  
1 Department of Anaesthesiology, Indira Gandhi Government General Hospital and PGI, Pondicherry, India
2 Department of Paediatric Surgery, Indira Gandhi Government General Hospital and PGI, Pondicherry, India

Correspondence Address:
Sandeep Kumar Mishra
Department of Anaesthesiology, Indira Gandhi Government General Hospital and PGI, Pondicherry
India




How to cite this article:
Mishra SK, Kavitha J, Kumaravel S, Lalatendu K K. Anesthestic management of a newborn for pedunculated teratoma of oral cavity.Anesth Essays Res 2010;4:124-125


How to cite this URL:
Mishra SK, Kavitha J, Kumaravel S, Lalatendu K K. Anesthestic management of a newborn for pedunculated teratoma of oral cavity. Anesth Essays Res [serial online] 2010 [cited 2021 Apr 13 ];4:124-125
Available from: https://www.aeronline.org/text.asp?2010/4/2/124/73524


Full Text

Sir,

A 2800-g male infant, born to a mother by vaginal delivery after 38 weeks gestation, presented with a pedunculated mass protruding from his mouth [Figure 1]. There was no respiratory distress. The mass was 5.1 cm in diameter, with a peduncle 1 cm in diameter. There was no associated anomaly. The mother did not have ultrasonography (USG) examinations done during her pregnancy. An excision biopsy was planned. After connecting the standard monitor, An intravenous (iv)access was secured and the baby preoxygenated with 100% oxygen by mask. Inj. Glycopyrolate 10 μg/kg iv and inj. Fentanyl 1 μg/kg iv were administered. Anticipating difficult mask ventilation, laryngoscopy and intubation, a check laryngoscopy (DL scopy) was planned with straight blade. Initially, the mass was gently pushed to left side followed by laryngoscopy. DL scopy revealed the pedunculated mass originating from hard palate [Figure 2] and Cormack Lehan grade 4 visualization of glottis. Keeping alternative airway (criothyroidetomy and jet ventilation/tracheostomy) as a standby procedures, the child was induced with sevoflurane up to 6 volume % under spontaneous respiration. On DL scopy, Cormack Lehan grade 3 was viewed (second attempt). The baby was intubated with size 3ID endotracheal tube and ventilation was assisted with pediatric breathing circuit and maintained with sevoflurane 4% and N 2 O and O 2. The mass was totally excised, and a profuse bleeding within short time (around 30 ml) from the attachment site was observed and controlled. The mucosal defect was repaired by suturing. Extubation was uneventful. Histopathologic examination revealed a mature teratoma.{Figure 1}{Figure 2}

Children with oral teratomas [1],[2] have less dramatic respiratory behavior compared with children having other head and neck presentations. When the oral teratomas grow, they usually tend to protrude outside the mouth, rather than posteriorly toward the oropharynx, [1] but if not pedunculated, it can lead to total airway obstruction. [1],[2] Children with oral teratomas have been reported to have associated anomalies [1],[2] including cleft palate, cystic hygroma and other multifocal teratomas. Various methods of intubation are described which include both conventional nasal intubation and fiberoptic nasal intubation. Miyoshi et al. described [3] a case in which mask ventilation and laryngoscopy were considered impossible and fiberoptic nasal intubation was successfully performed with topical anesthesia without sedation. We also expected difficult mask ventilation in our case, but we were able to perform laryngoscopy as the peduncle was not occupying measure working place for laryngoscopy. Diaz [4] described nasal intubation under inhalation induction with halothane in a case of pharyngeal teratoma where the peduncle of mass was also obstructing the right nasal airway. One advantage of nasal intubation is better working space available for surgeon. At the same time, approaching and dissection of the peduncle is difficult as the endotracheal tube would be in front of the cleft palate. Intubating with a preformed RAE tube would have been better in our case and it was not performed because of unavailability of appropriate sized tube. Sevoflurane is the preferred agent for induction because of smooth and faster induction. Induction with halothane has been described but it can cause bradycardia and arrhythmias. Though use of flexible fiberoptic intubation [3] has been described, considerable skill is required to perform it in a limited time frame as rapid emergence from inhalational agent may result in laryngospasm, particularly with sevoflurane. To conclude, goals of the management in a case of oropharyngeal teratoma include (a) careful assessments of airway and provision for alternative emergency surgical airway (b) exclusion of any congenital lesions (c) check laryngoscopy if possible and (d) establishment of reliable airway under inhalation induction, preferably with sevoflurane.

References

1Izadi K, Smith M, Askari M, Hackam D, Hameed AA, Bradley JP. A patient with an epignathus: Management of a large oropharyngeal teratoma in a newborn. J Craniofac Surg 2003;14:468-72.
2Becker S, Schφn R, Gutwald R, Otten JE, Maier W, Hentschel R, et al. Congenital teratoma with a cleft palate: Report of a case. Br J Oral Maxillofac Surg 2007;45:326-7.
3Miyoshi E, Kitamura S, Kinouchi K, Fukumitsu K, Nagai S. Anesthetic Management for Newborn Pharyngeal Teratoma. Jpn J Anesthesiol 1999;48:884-7.
4Diaz JH, Stedman PM, LeTard FX. Perioperative Management of Newborn Pharyngeal Teratomas. Anesthesiology 1984;61:608-10.