A case report of anesthetic management of a large tumor of the nape of neck in a child

Abstract

Large tumors of the head-and-neck region pose a challenge for the anesthetist, as often the anatomy gets disturbed in the area leading to difficulty in the airway management. Here, we report the case of a 2-year-old child with small round cell sarcoma of the neck with a 20 cm × 30 cm mass over the nape of the neck, extending from the occipital protuberance to C7 level and from the lateral margin of one sternocleidomastoid to the other, who was posted for subtotal excision of the swelling over the occipital and posterior cervical region under general anesthesia. The airway management was sought by introducing fiberoptic bronchoscope, and an endotracheal (ET) tube insertion was attempted which failed even after multiple attempts. Hence, a laryngeal mask airway (LMA) was inserted through which bronchoscope and ET tubes (ETTs) were inserted and airway was secured. Anesthesia was maintained with isoflurane and 0.1 mg/kg of atracurium and adequate opioids were given for analgesia. Surgeons described the tumor tissue to have brain tissue like consistency which caused difficulty in catching the bleeding vessels, and hence, there was massive intraoperative blood loss. Eventually, the child recovered well in the postoperative period and was discharged after a few weeks. Through our experience, we would like to suggest that pediatric anesthesiologists plan for fiberoptic intubation through the LMA as the first intubation attempt in a child with a potentially difficult airway, using two ETT's secured through a cut ETT connector. We would also like to highlight the importance of preparedness to handle massive blood loss in a round cell sarcoma.

Keywords

• difficult airway
• fiberoptic intubation
• large tumor of neck
• laryngeal mask airway endotracheal tube
• massive blood loss
• pediatric anesthetist