Anaesthetic challenges in a patient presenting with huge neck teratoma
A 3 year old girl, weighing 12 kg, presented to the out-patient department with a massive neck mass enlarging gradually over the past two year. She tends to fall forwards in upright position and had difficulty in breathing/strider in lying down posture. The base of the mass extended vertically from lower border of mandible up to clavicle inferiorly (approx. 18 × 12 cm in size) and on both sides approaching posterior triangle of neck (more towards left side). The mass was firm in consistency, non-translucent, non-tender with a shallow ulcer (2 × 2 cm size) at most dependent part []. Systemic examination/routine haematology was within normal limits. Skiagram and CECT of the neck/chest showed a soft tissue mass involving major vessels of neck with extra-thoracic extension up to the lower end of sternum and marked trachea deviation towards the right side (C4-T2 vertebral level) []. Cytology (FNAC) report was suggestive of teratoma. At the preoperative visit, her airway examination revealed Mallampatti grade III with restricted neck movements. She was graded as ASA II according to American Society of Anaesthesiologists risk classification.\nAs a part of pre-anaesthetic preparation, availability of adequate blood and difficult airway cart was ensured in the operation theatre. Patient was pre-medicated with glycopyrrolate 0.01 mg/kg IV, ondansetron 0.15 mg/kg IV. After pre-oxygenation, inhalational anaesthesia was induced with incremental doses of halothane (0.5% increment after every five breaths up to 3.0%) with 100% oxygen until intubating conditions were achieved. A cushion was placed under the shoulder to provide better laryngoscopic view. Two experienced anaesthesiologist participated in the procedure, one for holding the tumour mass and other for intubation. In the first attempt using Macintosh blade, intubation failed due to marked laryngeal deviation towards the right side (Cormach-Lehane grade 3). In the second attempt, using Magill blade, a 4.5 mm uncuffed endotracheal tube slided over the vocal cords but after that resistance was encountered. Immediately, a smaller size (4 mm) endotracheal tube was exchanged over the suction catheter (8.0 mm size) and trachea was now intubated, with confirmed bilateral air entry. Neuromuscular blockade was then facilitated with rocuronium (0.6 mg/kg IV) and a triple lumen central venous cannulation was done into right subclavian vein. Surgery was allowed to commence and anaesthesia was maintained with halothane, nitrous oxide/oxygen combination (60%/40%) and rocuronium (0.1 mg/kg IV) throughout surgery. The vitals remained stable throughout the operation and no major blood loss was there. A soft tissue mass weighing 2.75 Kg was excised during this procedure that lasted for about 2 hrs. At the end of surgery, after confirming adequate breathing efforts, neuromuscular block was reversed with neostigmine (0.05 mg/kg IV), glycopyrrolate (0.01 mg/kg IV). The patient was extubated and transferred to PACU. The patient remained stable throughout the postoperative period with no further complications.