Giant oral tumor in a child with malnutrition and sickle cell trait: Anesthetic challenges
An 8-year-old male child presented with a huge oral mass developing since last 1½ year []. He had shifted to liquid diet as oral cavity could not accommodate nor chew solid food. Poor feeding obtunded his growth and he weighed only 9 kg. He could sleep only in lateral position as severe snoring due to mass was noted in supine position. Obstruction however was not evident even in supine position once he was awake.\nHead and neck roentogram/Computed Tomography showed the tumor to be ossifying in nature [Figures and ] and a diagnosis of ossifying fibroma was to be confirmed after biopsy. He was referred to dental surgery where tumor excision biopsy was planned under general anesthesia.\nPre-operatively, he was evaluated for chronic malnourishment. Routine biochemical investigations showed hemoglobin of 6.4 mg/dl, total leucocyte count of 4800/ml, albumin of 2.2 gm/dl. Besides sodium and potassium, serum magnesium and calcium were evaluated for micronutrient deficiencies. Peripheral blood film showed hemolysis associated with sickling. Electrophoresis showed sickle cell hemoglobin to be less than 20% of total hemoglobin. Liver/renal function tests were unremarkable.\nNasal intubation was planned, as oral cavity was practically not accessible due to the mass []. Informed/written consent was obtained from father explaining possible need for post-operative ventilation. Pre-operatively anxiolytic was omitted to avoid possibility of obstruction due to sedation, however, anti-sialagogue (glycopyrollate-intravenous) was prescribed.\nAn intravenous line was secured by applying Eutectic Mixure of Local anesthetics in ward a day prior to surgery. One unit of packed RBCs (Red Blood Cells) was transfused and maintenance fluid drip (Ringer Lactate at 40 ml/h) was started during the fasting period.\nInhalation induction using sevoflurane in oxygen was planned to avoid likelihood of apnea associated with intravenous agents. After connecting routine monitoring, during pre-oxygenation no conventional available facemasks could fit patient's facial contours. Thus, inhalation induction using nasopharyngeal airway was planned. He was shifted to recovery where in parental presence nebulization with 4% lignocaine using simple facemask was carried out. On shifting back to operating room, 0.25 mg intravenous midazolam was given and xylometazoline drops were put in the right nares. A lubricated nasopharyngeal airway was inserted in to right nares and an endotracheal connector was inserted to its end where anesthesia circuit was attached. Sevoflurane in oxygen was used via the same circuit to induce anesthesia. Since the airway had bypassed the oropharynx [obstructive site due to tumor] the child did not obstruct and could be assisted while spontaneous breathing. He was simultaneously intubated with 5 mm PVC (Polyvinyl Chloride) uncuffed ETT (Endotracheal Tube) using the pediatric flexible fiber-optic bronchoscope via left nares.\nNo ventilatory difficulties were encountered during the surgery. The surgical team ruled out compression/involvement of tracheal wall by mass [], negating possibility of tracheomalacia that could become significant on extubation. During 2 h surgery he lost 50-70 ml of blood and received around 200 ml ringer lactate as maintenance fluid. He was electively ventilated overnight in intensive care unit and was extubated the next morning. No post-operative complications or airway obstruction was noted and he was shifted to the ward next evening.