Airway management in a four month old child with a large sublingual dermoid cyst

Sir,

A four-month-old infant weighing 5 kg presented with a large sublingual swelling, provisionally diagnosed as a dermoid cyst. The parents gave a history of noisy breathing while sleeping. The mass occupied almost the entire oral cavity, with a small portion of the tongue visible just below the upper lip. On crying or manual retraction of the upper lip, approximately 0.5 cm space could be seen between the tongue and the upper lip [Figure 1a]. Imaging revealed a 4.2 × 4.4 × 3.4 cm lesion with thin internal septa, inferiorly abutting muscles forming the floor of the mouth with no extension to the neck [Figure 1b and c]. The airway management plan included graded sedation with topicalisation of the airway and maintenance of spontaneous ventilation. Due to the unavailability of a fibreoptic endoscope at that time, we finalised our options as follows: plan A: video laryngoscope (VL) aided with stylet/bougie ± cyst aspiration; plan B: blind nasal intubation; plan C: elective tracheostomy. An emergency cricothyroidotomy needle was kept as a rescue oxygenation technique, and the cricoid cartilage and cricothyroid membrane were pre-marked under the supervision of the otorhinolaryngology team [Figure 2].

Figure 1.

(a) Sublingual mass occupying the entire oral cavity; (b) sagittal CT view of the growth; (c) axial CT view of the growth. CT: Computed tomography

Figure 2.

Use of tongue suture to lift the mass off the oropharynx

The preoperative preparation was initiated by obtaining intravenous (IV) access after applying a eutectic mixture of local anaesthetics patch and then shifting to the operating room. After injecting glycopyrrolate 50 μg IV, the child was sedated in a graded manner with IV fentanyl 2.5 μg initially while attaching the monitors. This was followed by IV dexmedetomidine 5 μg given over 10 min via an infusion pump. Simultaneously, nebulisation with 1 ml of 4% lignocaine was done.[1] Supplemental oxygen was given via nasal prongs at 4 L/min. The child gradually got sedated with a good spontaneous breathing pattern. 10% lignocaine was sprayed on the posterior pharyngeal wall and the tip of the tongue. A tongue suture was passed at this time by a round body needle to gently lift the tongue and the sublingual growth off the oropharynx [Figure 2]. This also helped to make space for the entry of the VL blade. Fentanyl 2.5 μg IV was administered before the video laryngoscopy attempt. The blade could be passed successfully below the mass and the tongue without any airway response. The lower part of the glottis could be visualised, just enough for inserting a paediatric gum elastic bougie over which a 4.5 mm ID flexo-metallic endotracheal tube was railroaded under the vision and fixed [Figure 2]. IV dexamethasone 1 mg was given to limit soft tissue oedema, and paracetamol 30 mg IV was given towards the end of the procedure.

The challenges in this case included difficult bag-mask ventilation, supraglottic airway insertion, conventional laryngoscopy, and patient cooperation. The key factor, in this case, was the maintenance of a spontaneous breathing patent airway, as there was a definite possibility of the mass obstructing the airway once the child was sedated. Dexmedetomidine was effective in the present case in providing a good level of sedation and blunting of airway reflexes without airway compromise.[2] Nevertheless, dexmedetomidine has been used in children as a sedative and analgesic adjunct intraoperatively for airway procedures.[3] We also used nebulised lignocaine to blunt the airway reflexes because the nebulised route allows rapid onset of drug action.[4] Preoperative aspiration of the cystic portion of the growth is another option to further improve airway access, although not required in the current case.[5,6] Applying a tongue suture before the laryngoscopy attempt also helped to improve airway access and maintain a patent airway.[5] Unlike other intraoral pathologies (which may be friable or vascular), there was no direct manipulation of the mass during airway management. For that reason, we attempted laryngoscopy with a VL. To conclude, each paediatric patient is different and requires a customised and safest possible airway technique. Nevertheless, no single gold standard technique guarantees absolute success in this age group.

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Conflicts of interest

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