Background

Mediastinal masses are heterogeneous collection of benign and malignant tumours. The anterior mediastinal masses, which most likely cause anaesthetic problems in children, are rapidly growing haematological malignancies, mostly lymphomas. Administering anaesthesia for diagnostic or surgical procedures to these patients is associated with a high risk of morbidity and mortality. Severe cardiovascular and/or respiratory collapse may occur following the induction of anaesthesia.

Keywords: anterior mediastinal mass, tracheal obstruction, bronchoscopy.

Case Report

We describe a case of a previously healthy 15-year-old girl who presented with a history of recurrent episodes of fever, neck pain and enlarged cervical lymph nodes. Physical examination revealed right-sided ptosis and miosis. Chest-x-ray showed a right mediastinal mass, measuring 12×7 cm. Echocardiography was normal. Magnetic resonance imaging, used to further delineate the exact location of the mass, revealed a tumour of a similar size with compression of both brachiocephalic veins and superior cava vein. The mass, mainly located at the right side of the mediastinum but extending also on the left side and into the neck, was in close contact with trachea and right main bronchus; trachea was pushed anteriorly.

To establish a precise diagnosis and start treatment, one percutaneous and two surgical biopsies of the tumour were performed under general anaesthesia within 18 days.

During each procedure surgical or anaesthesia-related complications were observed. Upon weaning from anaesthesia for the first biopsy (she was successfully intubated and mechanically ventilated), patient experienced severe hypoxemia due to pneumothorax, which resolved with chest tube insertion.

Second biopsy was performed under general inhalation anaesthesia with spontaneous ventilation and stridor persisted throughout.

For the third biopsy general anaesthesia with intubation and mechanical ventilation was performed. Patient developed mild hypotension and desaturated after induction, peak inspiratory pressure increased. After she was turned to a lateral position, situation was resolved.

Unfortunately, all three biopsies were non-diagnostic. CT scan of the chest was preformed and revealed the rapidly growing mass with diameter greater than 16 cm. Patient was treated with high doses of corticosteroids and was re-evaluated after 3 weeks. At that time, she was complaining of a fatigue, severe coughing episodes, and dyspnoea while lying flat. Paediatricians indicated another MRI, but examination could not have been done, as the girl was unable to lay flat. She became dyspnoeic, cyanotic and started coughing. Examination was postponed for next day; general anaesthesia was requested. Patient came walking for the MRI, she was mildly dyspnoeic and cyanotic. In a semi-sitting position, while she was still awake, her symptoms worsened. Anaesthesia with spontaneous breathing was planned, induction with careful boluses of propofol was preformed and I-gel inserted. Movements of respiratory muscles were present, but there was no effective ventilation. Ventilation with bag mask was also ineffective. After successful intubation, ventilation was still impossible because of obstruction of the distal airway. She desaturated, became bradycardic and eventually asystole appeared; CPR was started. With flexible bronchoscopy tracheal and right main bronchus obstruction was overcome with a small endotracheal tube No 5.5, fixated at its maximal depth. ROSC was achieved after 35 min. After 2 weeks in PICU, brain death was confirmed.

Conclusion

Anaesthetic management of diagnostic and surgical procedures in children with anterior mediastinal mass may present life-threatening challenges. This is usually caused by extrinsic compression of the airway, obstruction to the venous return or obstruction to cardiac output. The need for a tissue diagnosis and the risks associated with anaesthesia need to be balanced against each other. Careful assessment, interpretation of investigations and planning for possible complications is essential for all patients with a known anterior mediastinal mass before giving anaesthesia. Depending on the age and the ability to cooperate, use of local anaesthesia with sedation is considered the safest for biopsies in the high-risk patients.

Useful strategies to consider include awake fiberoptic intubation, maintenance of spontaneous ventilation, avoidance of muscle relaxant, intubation distal to the airway compression, positioning changes, immediate availability of bronchoscopy, and elective cardiopulmonary bypass in extreme cases.

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