anaesthetic management of an infant with vallecular cyst a challenging situation

Access this article online Quick response code Website: www.ijaweb.org DOI: 10.4103/0019-5049.100840 Anaesthetic management of an infant with vallecular cyst: A challenging situation

to achieve blind nasotracheal intubation of a patient

with temporomandibular joint ankylosis.[5] The

curvature of the ETT could now be easily changed

with the use of SDS, and the tip of the ETT entered

between the vocal cords fairly easily [Figure 1] but

impacted in the vestibule of the larynx Withdrawing

the SDS and raising the head slightly helped in

negotiation of the impacted ETT into the trachea

Correct tracheal intubation was further confirmed by

capnography During this procedure with the C-Mac

videolaryngoscope, the patient was administered 2%

sevoflurane in 100% oxygen via a 14 gauge catheter

attached to the side channel of the C-MAC blade

Oxygen saturation, mean arterial pressure and heart

rate remained between 97 and 99%, 68 and 98 mmHg

and 88 and102/min, respectively

In conclusion, a combination of D-blade of the C-Mac

videolaryngoscope and Schroeder’s directional stylet

may provide an alternative strategy for tracheal

intubation in patients with restricted mouth opening,

with the added advantage of oxygenation during

intubation

Abdullah M Al-Jadidi, Rashid M Khan,

Sujit V Nair, Naresh Kaul

Department of Anaesthesia and ICU, Khoula Hospital, Muscat,

Sultanate of Oman

Address for correspondence:

Dr Naresh Kaul, Department of Anaesthesia and ICU, National Trauma Centre, Khoula Hospital,

PO Box 514, Postal Code 118,

Al Harthy Complex, Sultanate of Oman

E-mail: drnareshkaul@gmail.com

Figure 1: Schroeder’s directional stylet in endotracheal tube aiding

entry into the glottis using D-blade of the C-Mac videolaryngoscope

REFERENCES

1 Aiello G, Metcalf I Anaesthetic implications of temporomandibular joint disease Can J Anaesth 1992;39:610-6.

2 Kulkarni DK, Prasad AD, Rao SM Experience in fiberoptic nasal intubation for temporomandibular joint ankylosis Ind J Anaesth 1999;43:26-9.

3 Maassen R, Lee R, Hermans B, Marcus M, van Zundert A

A comparison of three videolaryngoscopes; the Macintosh laryngoscope blade reduces, but does not replace, routine stylet use for intubation in morbidly obese patients Anesth Analg 2009;109:1560-5.

4 Behringer EC, Kristensen MS Evidence for benefit vs novelty in new intubation equipment Anaesthesia 2011;66, Suppl 2:57-64.

5 Mahajan R, Shafi F, Sharma A Use of Shroeder’s directional stylet to enhance navigability during nasotracheal intubation

J Anesth 2010;24:150-1.

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10.4103/0019-5049.100840

Anaesthetic management of an infant with vallecular cyst:

A challenging situation

Sir, Congenital vallecular cyst, although rare, is an important condition leading to stridor and complete airway obstruction in infants, which may be precipitated by various factors such as feeding, crying, induction of anaesthesia or even during awake fibreoptic bronchoscopy Different techniques have been described in the literature for securing the airway, and each one has its own merits and demerits

We report one such case in which the airway could not be secured by any of the conventional techniques described for such cases; thus, necessitating tracheostomy

A 3-month-old male baby weighing 2.5 kg presented with coughing and vomiting following feeds and failure to thrive The respiratory rate was 38/min, with minimal intercostal recession There was no cyanosis

or stridor Oxygen saturation on room air was 98% Diagnosis of vallecular cyst was made after computed tomography scan of the neck [Figure 1]

Vallecular cyst, although benign, carries a potential threat of hypoxia and death if not managed appropriately.[1] Laryngomalacia is associated in 90% of cases.[2] After reviewing the literature, it was observed that no specific technique has been clearly outlined for such a tricky situation All techniques, such as paraglossal laryngoscopy, awake fibreoptic bronchoscopy, inhalation induction and even intubation after muscle relaxation and cyst aspiration, have been attempted.[3-5] Paraglossal laryngoscopy has been successfully executed in two cases.[3,4]

A pre-operative awake fibreoptic bronchoscopy under local anaesthesia may appear to be the safest technique, but is difficult even in expert hands because

of the limited space available for manipulation of the scope in the hypopharynx and distorted laryngeal anatomy Moreover, the danger of airway obstruction still remains in the case of failure of fibreoptic bronchoscopy.[3]

In light of these facts and the absence of stridor and cyanosis in an otherwise active infant, we decided

to secure the airway by a paraglossal technique after inhalation induction

Paraglossal laryngoscopy failed to reveal any laryngeal structure This could be attributed to the fact that the cyst was adherent to the epiglottis, which could not be lifted Although muscle relaxants have been used to facilitate laryngoscopy, a high incidence of associated laryngomalacia and fear of airway collapse and complete airway obstruction precluded the use

of muscle relaxants in our case Cyst aspiration can

be associated with a risk of pulmonary aspiration, increased recurrence rate and difficulty in identifying cyst margins upon subsequent surgery.[3] Hence, a decision to establish a surgical airway was made for cyst excision Tracheostomy in an infant itself is

a demanding skill on the part of the surgeon due to difficult anatomy and precarious respiratory reserve

To conclude, anaesthetic management of infants with vallecular cysts requires meticulous planning and individualised approach Guiding factors for the anaesthetic plan are age and pre-operative symptomatology of the child, size and location of the cyst and, above all, expertise of the anaesthesiologist and facilities at hand for paediatric airway management Preparedness for tracheostomy should always be present, especially in the absence of a neonatal fibreoptic bronchoscope, as surgical airway

Figures 1: Computed tomography scan of the vallecular cyst

The child was scheduled for excision of the cyst An

inhalation induction with intubation was planned

Surgeons were asked to be standby for emergency

tracheostomy, considering the high risk of loosing the

airway and non-availability of a neonatal fibreoptic

bronchoscope An intravenous line was secured

after induction of anaesthesia with halothane in

100% oxygen After confirming mask ventilation,

5 mg propofol was supplemented and laryngoscopy

attempted with Miller size 0 laryngoscope introduced

by a paraglossal approach; but, a cystic swelling was

visible in front of the tip of the blade that could not

be deflected to either side or lifted up Immediately,

a decision to perform tracheostomy was made

However, as tracheostomy was being performed, mask

ventilation became difficult and oxygen saturation

dropped to 70% Pink frothy secretions were noted

in the oral cavity and nostrils suggestive of negative

pressure pulmonary oedema The patient’s neck was

extended and turned to the right to facilitate ventilation

thereby improving the saturation to 90% Meanwhile,

a size 3 uncuffed tracheostomy tube was secured in

place Ventilation was facilitated by 1 mg atracurium

After this, the saturation rose to 98% and the chest

cleared gradually Anaesthesia was maintained with

isoflurane in oxygen and 5 µg fentanyl A check

laryngoscopy was carried out to assess if muscle

relaxation improved the glottic view, but neither the

epiglottis nor the arytenoids could be visualised The

cyst was excised by an extraoral approach Residual

neuromuscular blockade was reversed and the baby

was shifted to the Intensive Care Unit for further

observation The trachea was decannulated after

2 weeks and the baby has been doing well since

Parental consent was obtained for publication of this

clinical scenario for educational purposes

may be the only option left, especially in an emergency

situation

Upma Bhatia Batra, Suniti Kale, Amita Malik1

Departments of Anaesthesiology and Intensive Care, 1 Department of

Radiodiagnosis, VMMC, Safdarjung Hospital, New Delhi, India

Address for correspondence:

Dr Upma Bhatia Batra, Departments of Anaesthesiology and Intensive Care VMMC,

Safdarjung Hospital, New Delhi, India

E-mail: ubhatia2004@gmail.com

REFERENCES

1 Gutierrez JP, Berkowitz RG, Robertson CF Vallecular cysts in

newborns and infants Pediatr Pulmonol 1999;27:282-5.

2 Liu HC, Lee KS, Hsu CH, Hung HY Neonatal vallecular

cyst: Report of eleven cases Changgeng Yi Xue Za Zhi

1999;22:615- 20.

3 Cheng KS, Li HU, Hartigan PM Vallecular cyst and

laryngomalacia in infants: Report of six cases and airway

management Anesth Analg 2002;95:1248-50.

4 Kalra S, Saraswat N, Kaur R, Agarwal RA Vallecular cyst

in a newborn: A challenging airway management Anaesth

Intensive Care 2011;3:509-10.

5 Gandhi S, Raza SA, Thedekar P, Mishra P Congenital vallecular

cyst with laryngomalacia: A report of two cases J Laryngol

Voice 2011;1:27-9.

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DOI:

10.4103/0019-5049.100842

Should ultrasonography check be

routinely done following removal

of femoral vascular catheter in

patients with end-stage renal

disease?

Sir,

With the increasing use of femoral vascular catheter

in intensive care unit (ICU), the insertion related

complications of them are dealt seriously.[1,2] But,

scarcity of reports about complications following

removal of femoral vascular catheter encourage us to

report two interesting, potentially fatal complications

of femoral vascular catheter removal in end-stage

renal disease (ESRD) patients The importance

of bedside ultrasonography (USG) after femoral vascular catheter removal has been stressed in this communication

CASE 1

A 22-year-old student was transferred to our ICU with hospital-acquired pneumonia with ESRD due

to obstructive uropathy On admission, he was conscious, haemodynamically stable, tracheostomised

on mechanical ventilation and pale (haemoglobin 8 gm/dl) He had mildly deranged prothrombin time (3 seconds prolonged) and normal platelet count

He had left femoral dialysis catheter (DC) (12 Fr,

18 cm, Mahurkar) in situ Since, the insertion site was erythematous, we removed DC No oozing was visible A new DC was placed in right femoral vein uneventfully under USG guidance Two days later, patient complained of left thigh pain His left thigh and groin area was found warm, tender and slightly swollen Urgent bedside USG and Doppler of that region showed large haematoma (12×10 cm) just posterior to the femoral vessels with intact vascular flow [Figure 1] The patient developed septic shock with haemoglobin drop (6 gm/dl) on next day In view of increasing groin swelling and impending compartment syndrome, surgical drainage was arranged A large haematoma and pus was removed Microbiology revealed growth of Staphylococcus aureus-sensitive

to vancomycin from the pus and contemporary blood cultures He showed clinical improvement within 48 hrs of intravenous vancomycin therapy

CASE 2

A 72-year-old obese retired nurse, with hypertensive heart disease and ESRD was referred to our ICU for extensive cellulitis of the left leg leading to septic shock For invasive blood pressure monitoring, we put a right femoral arterial catheter (7 Fr, Certofix mono, B Braun) uneventfully under USG guidance However, the patient recovered from septic shock within 3 days Her haemoglobin, prothrombin time and platelet counts came to normal limits Decision was made to remove the femoral catheter After 2 days

of removal of catheter, patient complained of right thigh pain On palpation, some indurations were felt

A bedside lower limb USG showed a large haematoma anterior to common femoral artery, approximately 120-ml volume A lower limb computed tomography angiogram [Figure 2] showed a pseudoaneurysm

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