Difficult Airway Management in Pediatric with a Large Cystic Hygroma Colli Undergoing One-Stage Excision Surgery

Abstract

Background: A large cystic hygroma colli is a complicating factor in airway management in pediatric. Proper preparation, planning, and anticipation can reduce the risk of complications, morbidity, and mortality during difficult airway management. The fundamental principle of difficult airway management is to maintain adequate oxygenation and avoid hypoxemia by maintaining spontaneous ventilation. Case: A 22-month-old girl, weighing 9 kg, diagnosed with a large cystic hygroma colli who underwent single-stage excision surgery. Cystic hygroma was experienced since birth and with age, the cysts enlarge to a size of 25 x 17 x 12 cm which extends towards the face and shoulders. The patient did not experience stridor and symptoms of airway obstruction. The chest x-ray reveals no expansion of the cyst into the chest cavity and showed minimal tracheal deviation to the right. The difficult airway management was accomplished while maintaining the patient's spontaneous breathing. Sedation and analgesia obtained with intravenous administration of dexmedetomidine, ketamine, and nebulized lidocaine. A video laryngoscope is used to facilitate intubation. Awake extubation was performed after confirming that there was no risk of complications of laryngeal edema, laryngeal nerve injury, and tracheomalacia using a cuff-leak test. Conclusion: Maintaining spontaneous breathing, optimal levels of sedation and analgesia by administering dexmedetomidine, ketamine, and nebulizing lidocaine, and the use of a video laryngoscope can provide successful management of difficult airways due to a large cystic hygroma colli in pediatric patients.

An Innovative Airway Management of an Anticipated Difficult Airway in a Pediatric Patient with Cervical Cystic Hygroma: A Case Report

“…Favorable results have been achieved with induction of cystic hygroma patients using ketamine, midazolam and ketamine combination as well as ketamine and dexmedetomidine combination. 8 , 12 , 13…”

“…Favorable results have been achieved with induction of cystic hygroma patients using ketamine, midazolam and ketamine combination as well as ketamine and dexmedetomidine combination. 8,12,13 In the index patient, midazolam, ketamine, and remifentanil infusion were used to induce loss of consciousness and provide analgesia during intubation while maintaining spontaneous ventilation. Use of remifentanil infusion during the maintenance phase afforded sufficient sedation with rapid elimination of its effects upon infusion discontinuation.…”

“…21 There are documented cases with the successful use of video laryngoscope in these patients. 8,11 Although only 18% used it as the first tracheal intubation technique for difficult pediatric tracheal intubation encounters, it has a more favorable first attempt success rate of 55%. 21 It was not considered for this patient due to the significant extension in the oral cavity.…”

“…Existing literature have described the use of intramuscular, intravenous, and inhalation induction as well as the use of conventional laryngoscope, video laryngoscope, and fiberoptic scope. [7][8][9][10][11][12] This paper aims to describe an intravenous induction technique coupled with a novel way of using a nasopharyngeal airway to facilitate fiberoptic nasotracheal intubation in a child with cervical cystic hygroma.…”