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Table of Contents    
CASE REPORT
Year : 2020  |  Volume : 68  |  Issue : 1  |  Page : 168-169

A Case of Large Intraoral Teratoma with Intracranial Extension: Peri‑Operative Challenges


Division of Neuroanaesthesiology, Department of Anaesthesiology and Critical Care, JIPMER, Pondicherry, India

Date of Web Publication28-Feb-2020

Correspondence Address:
Dr. Prasanna U Bidkar
In Charge Division of Neuroanaesthesiology, Department of Anaesthesiology and Critical Care, JIPMER, Pondicherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.279687

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 » Abstract 


A 40-day-old female child presented to us with an oral cavity mass, noticed at birth and progressively increasing in size. Preoperative computed tomography revealed intracranial extension of the lesion. Airway management, securing and maintaining invasive vascular access peri-operatively and transport of the patient to MRI suite were the major challenges. Mask ventilation was difficult and successful intubation required three attempts. Otorhinolaryngologists were present in the theatre during induction to perform a tracheostomy if the situation so demanded.


Keywords: Difficult airway, intracranial extension, teratoma
Key Messages: Intraoperative teratoma with intracranial extensions pose majore perioperative challenges. Difficult airway, Prolonged surgery and major blood loss are key considerations. A multidesiplinary team approach is needed for management of such cases.


How to cite this article:
Bidkar PU, Bangera R, Ramjeevan R, Dey A, Mishra SK. A Case of Large Intraoral Teratoma with Intracranial Extension: Peri‑Operative Challenges. Neurol India 2020;68:168-9

How to cite this URL:
Bidkar PU, Bangera R, Ramjeevan R, Dey A, Mishra SK. A Case of Large Intraoral Teratoma with Intracranial Extension: Peri‑Operative Challenges. Neurol India [serial online] 2020 [cited 2020 Mar 28];68:168-9. Available from: http://www.neurologyindia.com/text.asp?2020/68/1/168/279687




The incidence of teratoma is about 1 in 4000 live births, with a female preponderance.[1] While sacro-coccygeal teratoma accounts for the majority of them, oropharyngeal teratoma is quite rare, accounting for only 2% of all teratomas. Oropharyngeal teratoma, by virtue of their location, may pose several challenges pertaining to airway management.[2],[3] They may have a varied clinical presentation, but usually present with difficulty in swallowing and breathing and may require emergency airway management. We report a case of a 40-day-old infant who presented to us with an oral cavity mass associated with a cleft palate, extending intracranially, for surgery.


 » Case History Top


A 40-day-old term, female child, weighing 2.6 kg, presented with an oral cavity mass noticed at birth. The tumour had been progressively increasing in size, until it acquired the present size of 6 * 6 cm. There was no history suggestive of any airway obstruction. The tumor occupied almost the entire oral cavity and complete assessment of the airway was not possible. Cleft palate was also associated with the mass. Preoperative hemodynamic parameters and blood investigations were within normal limits. Preoperative CT scan showed a large solid mass with cystic areas 6 * 6 involving gingivoalveolar region on the right side extending into the infratemporal fossa, with an erosion of the greater wing of the sphenoid and petrous bone, extending extradurally into the middle cranial fossa [Figure 1]. Preoperative MRI couldn't be done under sedation in view of anticipated difficult airway. This also made formulating a plan for surgical approach in advance difficult. In addition, the surgery was expected to involve multiple changes in position in order to facilitate surgical access, thus adding to the challenges faced by the surgeons. Removal of the intraoral and the intracranial portions of the tumour required a multidisciplinary team comprising plastic surgeons and neurosurgeons. The duration of the surgery was also another factor making the surgery a challenging one.
Figure 1:(a) Intraoral tumor. (b) Post induction of anaesthesia showing space available for an endotracheal tube. (c and d) MRI showing intraoral part (1), maxillary part and intracranial, an extradural extension of tumor

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Intravenous line using a 24 G cannula was secured in the preoperative period. Difficult airway cart was kept ready with ENT surgeons available in the operation theatre for emergency tracheostomy, if required. Anaesthesia was induced with incremental doses of sevoflurane. Initial mask ventilation was difficult. A gentle jaw thrust with two-person assisted technique was employed. After achieving an adequate depth of anaesthesia, intravenous fentanyl 5 microgram was administered. Direct laryngoscopy was attempted using size 0 MacIntosh blade. However, the blade could not be negotiated in the oral cavity. A second attempt was made using size 1 Miller blade, with BURP manoeuvre. A FROVA introducer was passed into the trachea, but 3.5 sizes endotracheal tube could not be passed into the glottis over the introducer. The third attempt using a 3.0 size uncuffed, styletted endotracheal tube was successful. Endotracheal intubation was confirmed by auscultation and continuous square waveform capnography. The patient was then paralysed using 0.2 mg vecuronium. Subsequently, the right internal jugular vein was cannulated using a 4.5 Fr double lumen central line and the left femoral artery was cannulated using ultrasound guidance. The child was then shifted to the MRI suite for further scans and subsequently shifted back to the operating room. During transport and in MRI suite, anesthesia was maintained with 100 mcg/kg/min of propofol infusion. The surgery lasted 12 hours. Blood loss was approximately 100 ml and it was replaced with PRBC. The child was shifted to the Neurointensive care unit for elective ventilation. She was extubated on postoperative day 2.


 » Discussion Top


Oral teratomas almost invariably render mask ventilation as well as intubation difficult or even impossible. Izadi et al. reported management of a large oropharyngeal teratoma in a neonate by performing a tracheostomy followed by excision of the tumour.[4] We were able to successfully intubate the trachea using direct laryngoscopy and an uncuffed tube reinforced with a stylet, in the third attempt. Unavailability of paediatric video laryngoscope compounded our problem. Mishra et al. managed an infant with a pedunculated mass protruding from the mouth, using direct laryngoscopy, to successfully intubate the child in the second attempt.[5] We faced additional challenges in that sedation for a preoperative MRI was declined in view of anticipated difficult airway. The child was shifted to the MRI suite after intubation and after securing invasive lines. Mobilising an intubated child and maintaining anaesthesia outside the operation theatre is fraught with complications. We maintained anaesthesia in the MRI suite using an infusion of propofol. Maintaining patency of invasive lines in the MRI suite was also challenging. The child was subsequently shifted to the operation theatre and anaesthesia was maintained with sevoflurane and timed doses of vecuronium. Aggressive attempts were made to prevent hypothermia. Postoperative ventilation is often essential in these patients in view of oral edema and prolonged surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Vandenhaute B, Leteurtre E, Lecomte-Houcke M, Pellerin P, Nuyts JP, Cuisset JM, et al. Epignathus teratoma: Report of three cases with a review of the literature. Cleft Palate Craniofac J 2000;37:83-91.  Back to cited text no. 1
    
2.
Moreddu E, Pereira J, Vaz R, Lena G, Triglia JM, Nicollas R. Combined endonasal and neurosurgical resection of a congenital teratoma with pharyngeal, intracranial and orbital extension: Case report, surgical technique and review of the literature. Int J Pediatr Otorhinolaryngol 2015;79:1991-4.  Back to cited text no. 2
    
3.
Jarrahy R, Cha ST, Mathiasen RA, Shahinian HK. Congenital teratoma of the oropharyngeal cavity with intracranial extension: Case report and literature review. J Craniofac Surg 2000;11:106-12.   Back to cited text no. 3
    
4.
Izadi K, Smith M, Askari M, Hackam D, Hameed AA, Bradley JP. A patient with an epignathus: Management of a large oropharyngeal teratoma in a newborn. J Craniofac Surg 2003;14:468-72.  Back to cited text no. 4
    
5.
Mishra SK, Kavitha J, Kumaravel S, Lalatendu KK. Anesthestic management of a newborn for pedunculated teratoma of oral cavity. Anesth Essays Res 2010;4:124-5.  Back to cited text no. 5
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