Airway management of a child with haemangioma tongue for dynamic airway assessment

Sir,

Oral haemangiomas require surgical intervention when airway compromise occurs.[1] A 3-year-old girl child having haemangioma from infancy had undergone debulking of tongue followed by tracheostomy 2 months back. Tracheostomy was decannulated on the third postoperative day. She now presented to our hospital with recurred haemangioma and occasional stridor while crying. She was haemodynamically stable with room air saturation of 98%. The tongue looked bulky and filled the entire oral cavity [Figure 1a]. She had symptomatic relief with intravenous steroids and was posted for dynamic airway assessment (DAA).

Figure 1.

(a) Haemangioma tongue and (b) facemask being held over pulled out tongue

Following intravenous glycopyrrolate 0.05 mg, inhalation induction with 8% sevoflurane in oxygen was attempted which resulted in complete airway obstruction with flat end-tidal carbon dioxide (ETCO₂) tracing. An assistant then pulled the enlarged tongue out, and a larger face mask was firmly held over the pulled out tongue [Figure 1b] which relieved the airway obstruction. When the plane of anaesthesia was adequate, the face mask was removed, flexible laryngoscope was passed nasally and DAA was performed keeping the child breathing spontaneously. Airway patency was maintained by keeping the tongue pulled out with jaw thrust and chin lift. The face mask was kept near mouth with oxygen flow at 15L/min for paraoxygenation. DAA took <1 minute which showed tracheomalacia at the previous tracheostomy site. After procedure, the tongue was kept pulled out till child was awake and started maintaining airway. Postoperatively, adrenaline nebulization was administered, and intravenous steroids were continued.

Airway haemangioma manifests frequently with stridor. Airway endoscopy is the gold standard for diagnosis and follow-up as it allows identification of precise location and cause of obstruction.[2] Airway obstruction is common after induction of general anaesthesia.[3] In the presence of macroglossia, maintaining spontaneous breathing during induction is vital. Therefore, inhalation induction is considered advantageous over intravenous induction as it ensures faster recovery, if apnoea or airway obstruction occurs. Because of the same reason, we avoided ketamine. In patients with macroglossia, pulling the bulky tongue out provides room for placement of laryngoscope blade behind the tongue and endotracheal tubes (ETT) to be passed.[4] Larger face mask may be required to maintain airway seal when held over the pulled out tongue. We did not insert oral airway as tongue was fully occupying oral cavity and also to avoid trauma. Since extent of haemangioma posteriorly up to laryngeal inlet was suspected, the use of nasopharyngeal airway was also not considered.

An alternative technique would have been insertion of laryngeal mask airway (LMA) and performing DAA through LMA maintaining spontaneous breathing. However, our patient had inadequate space for placement of LMA with a high chance of trauma on insertion. There was no bleeding while we pulled the enlarged tongue out possibly because of gentle handling and fibrosis secondary to prior steroid injections and surgery as well. In case of bleeding during procedure, isolation of airway with cuffed ETT using videolaryngoscope would have been required.

It is concluded that the simple manoeuvre of pulling the tongue out to relieve airway obstruction following induction of general anaesthesia is a safe and effective measure to maintain airway patency in children with haemangioma tongue.

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Conflicts of interest

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