Anesthetic management of congenital epulis in a newborn: a case report

Introduction:

The epulis of the newborn is a granular cell tumor that originates from the mucosa of the gingiva.

Case presentation:

The authors report a case of a 4-day-old neonate with a large mass arising from the right upper gingival area and occupying most of the oral cavity who presented for surgery with a potentially difficult airway. Intubation was achieved uneventfully using a gaseous induction with an appropriate-size facemask and displacement of the epulis to allow cautious laryngoscopy.

Discussion:

General anesthesia offers good airway protection and also alleviates the stress and pain associated with the surgery.

Conclusion:

Congenital epulis is a relatively rare congenital tumor of a newborn, which is one of the causes of difficult airways in neonates and children. However, after slight manipulation of the tumor, endotracheal intubation for the administration of general anesthesia is attainable.

Introduction

Highlights

• Congenital epulis is a rare benign growth of gingiva in neonates which is one of the causes of a difficult airway.

• General anesthesia can be a safe mode of anesthesia in case of congenital epulis.

• Intubation is possible after slight manipulation of mass with an assistant.

Congenital epulis (also known as congenital gingival granular cell tumor) is a rare benign growth of gingiva of the neonates. It was first described in 1871 by Neumann1, so it is also called Neumanns’ tumor. It usually presents at birth with a mass arising from the mucosa of the gingiva, commonly from the maxillary alveolar ridge, and is seen as a mass protruding out of the neonate’s mouth which may hamper respiration or feeding or both. It shows a marked female preponderance of 8 : 12. The usual presentation on examination is a pedunculated, nonulcerated, pink, firm mass ranging from a few millimeters to 9 cm in diameter3. Surgical removal is regarded as the treatment of choice for congenital epulis4.

We here describe the anesthetic management using general anesthesia of a newborn for excision of congenital epulis who presented to a tertiary care center in Nepal. Our case provides additional evidence of the safety and effectiveness of general anesthesia in the management of congenital epulis since there are no definitive recommendations. This case report has been reported in line with the SCARE guidelines5.

Case presentation

A 4-day-old female neonate whose weight was 3.36 kg had a large mass arising from the right upper gingival area occupying most of the oral cavity (Figure 1). She was scheduled for operative management with excision and biopsy. The initial diagnosis of the mass was congenital epulis. Before the operative procedure, all baseline investigations were sent and the findings were normal. Other congenital anomalies were ruled out.

Figure 1.

A large mass from the maxillary gingival ridge.

On local examination, a firm mass of around 2.5×2.5 cm was found on the maxillary anterior alveolar region which was pedunculated, pinkish-reddish, and nonpulsatile. General anesthesia was planned for the excision of the mass. The patient was kept Nil per oral as per ASA American Society of Anesthesiologists Guidelines and 5% dextrose as maintenance fluid was started right away by securing a 24 G IV line at the right hand. At the operation theater, Ringer lactate was switched as an intravenous maintenance fluid at the rate of 20 ml/h. Before induction preoxygenation was done with 95% oxygen, after intubation saturation was maintained at 95% by lowering FiO₂ to 50%. Injection glycopyrrolate 0.01 mg/kg, and injection ketamine 0.5 mg/kg was administered intravenously following which gaseous induction with 8% sevoflurane was done. After confirmation of ventilation, 1.5 mg/kg of succinylcholine was administered to facilitate endotracheal intubation. We were able to successfully intubate the neonate with a 3 mm uncuffed endotracheal tube at the second attempt with the No.1 Macintosh blade with the assistant displacing the mass out after which we were able to see the epiglottis and posterior part of the vocal cords. After securing the airway Injection vecuronium 0.1 mg/kg was given to paralyze the patient. Anesthesia was maintained with 2.5% sevoflurane with 50% oxygen. Injection paracetamol 15 mg/kg intravenously and fentanyl 2 µg/kg intravenously were given for analgesia. After completion of the surgery, the neuromuscular blocking agents were reversed using a mixture consisting of 0.05 mg/kg neostigmine and 0.01 mg/kg glycopyrrolate. The neonate was extubated after she was fully awake. The surgery was uneventful and the postoperative transition was also smooth. The patient had no postoperative complications. Postoperative SpO₂ was 94% on room air and had a heart rate of 160 beats per minute (Fig. 2).

Figure 2.

Postoperative image showing the site of the wound.

Discussion

Congenital epulis is one of the causes of difficult airways in neonates and children. The main concerns for us as a team of anesthesiology were difficulty in mask ventilation and laryngoscopy due to the tumor obstructing the airway. Also, the vascular nature of the tumor poses an increased risk of bleeding6.

There is no single recommendation for the anesthetic management of congenital epulis. General anesthesia can be a safe mode of anesthesia in patients with congenital epulis7,8. There have also been reports of the tumor being excised ‘without anesthesia’7,9. However, in case of nonemergency situations, alleviation of pain and stress associated with the surgery is important. Local anesthesia has also been performed by infiltrating the anesthetic in the base of the pedicle and administering intravenous anesthesia without intubation9. The use of local anesthesia minimizes the complications associated with general anesthesia, however, as the child is likely to move and cry during the surgery, there may be difficulty in excising the tumor and achieving adequate hemostasis10.

However, general anesthesia offers good airway protection and also alleviates the stress and pain associated with the surgery9. Considering the vascular nature of the tumor there could be bleeding, which would jeopardize the patient’s airway, so we decided against local anesthesia in this case. Also, general anesthesia optimizes surgical conditions and allows for easier excision of the tumor. In the case presented to us, the pedunculated and mobile nature of the mass helped us secure airway access after slight manipulation of the tumor by an assistant. Mask ventilation was achievable, so we decided to perform endotracheal intubation by giving muscle relaxants. If the mass was not mobile, there may be a need for a laryngeal mask airway and a fiber optic bronchoscope11.

Conclusion

In conclusion, congenital epulis is a relatively rare congenital tumor of a newborn that may make breathing and oral feeding difficult if early excision is not performed. It is one of the causes of difficult airways in neonates and children. However, after slight manipulation of the tumor, endotracheal intubation is attainable and general anesthesia can offer a safe mode of anesthesia for the excision of congenital epulis.

Ethical approval

Patient anonymity is maintained throughout this manuscript, and consent was obtained for publication from the patient’s parents.

Consent for publication

Written informed consent was obtained from the patient’s parents for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

No sources of funding.

Author contribution

S.R.: concept, manuscript edit and review, and guarantor. M.D., A.D., B.T., P.T., and A.C.: manuscript preparation, edit and review. B.T.: data collection, obtaining consent from the patient, manuscript review.

Conflicts of interest disclosure

All authors declare that they have no conflicts of interest.

Research registration unique identifying number (UIN)

NA.

Guarantor

Sangina Ranjit, Associate Professor, Department of Anesthesia and Critical Care, Dhulikhel Hospital, Dhulikhel, Kavre.

Provenance and peer review

Not commissioned, externally peer-reviewed.