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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 3  |  Issue : 4  |  Page : 188-190

Anesthetic management of a newborn with a huge tongue teratoma: a case report


Department of Anaesthesia and Critical Care, Umaid Hospital under S.N. Medical Collage, Jodhpur, Rajasthan, India

Date of Submission09-Oct-2015
Date of Acceptance03-Mar-2016
Date of Web Publication16-Dec-2016

Correspondence Address:
Babita
d/o Mahilal, Behind Tehseel, Chamad Gali, Ward No. 6, Nagar (Tehseel), Bharatpur (Dist.) 321205, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2356-9115.195880

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Keywords: airway management, newborn, tongue teratoma


How to cite this article:
Babita, Singh B, Gupta M, Garg D. Anesthetic management of a newborn with a huge tongue teratoma: a case report. Res Opin Anesth Intensive Care 2016;3:188-90

How to cite this URL:
Babita, Singh B, Gupta M, Garg D. Anesthetic management of a newborn with a huge tongue teratoma: a case report. Res Opin Anesth Intensive Care [serial online] 2016 [cited 2018 Dec 13];3:188-90. Available from: http://www.roaic.eg.net/text.asp?2016/3/4/188/195880

Teratomas are true neoplasms composed of tissues from all three germinal layers and may exhibit variable levels of maturity. They have an unknown origin and eccentric microscopic appearance. Airway control is most challenging in such patients. In this case, we describe the anesthetic management of a patient with a large tongue teratoma that was successfully treated with surgery.


  Introduction Top


Teratomas are defined as true neoplasms composed of multiple tissues, foreign to the site from which they originate. They are the most common extragonadal germ-cell tumors occurring in childhood, consisting of tissues from at least two of the three germ layers. These tumors are most often benign in their histology, but result in a high degree of morbidity and possible mortality by virtue of their size and location, causing airway obstruction and respiratory distress. They arise most commonly in a midline or paraxial location in the sacrococcygeal region. Ninety percent of head and neck teratomas present during the neonatal and infantile period, predominantly involving the neck and nasopharynx, and occur in one in every 20 000–40 000 births [1]. Of the head and neck teratomas, pure oral presentation is especially rare, with most of the cases involving the tongue [2].


  Case report Top


A 3.2-kg male baby was born at 38 weeks of gestation with a mass protruding from his mouth ([Figure 1]). The mother did not undergo ultrasonography examinations during her pregnancy, and presented to the emergency room for the first time at term. An emergency cesarean section was carried out because of fetal distress. A male child was born with a large tumor protruding from the oral cavity. The mass was bleeding because of handling, had a smooth and firm surface, and originated from the tongue. The baby had respiratory distress because the mass caused airway obstruction. There were copious secretions in the mouth. Intubation attempts were made but failed. Therefore, oxygen was supplied through a nasal cannula, and the baby obtained some relief. The patient was shifted to the operation theater immediately, and excision of the tumor was scheduled. Any associated congenital malformation was not detected. The tongue was also protruding along with the mass. In the operation theater, equipment necessary to manage a difficult airway were kept ready. The possibility of tracheotomy was also mentioned to the parents. The infant was positioned supine, and monitors were attached; the intravenous line was secured. The patient was oxygenated with 100% oxygen through a nasal cannula. The patient was premedicated with injected atropine 0.01 mg/kg and injected ondansetron 0.1 mg/kg. The patient was administered ketamine 2 mg/kg. One puff of 10% lignocaine was sprayed on the vocal cord area. Next, size 0 Miller's laryngoscope blade was carefully introduced through the left mouth corner with an assistant gently pulling the tumor aside. The blade tip was directed posteromedially, and a part of the glottis could be visualized (Cormack and Lehane grade III) with the aid of gentle external manipulation of the larynx. We then threaded a 2.5-mm internal-diameter uncuffed endotracheal tube into the trachea under visual guidance after a couple of attempts to align the tube tip to the glottic opening. After confirmation of correct placement, the tube was fixed, and a pharyngeal pack was passed around the tube to avoid aspiration of blood. Ventilation was assisted by a pediatric breathing circuit and maintained with sevoflurane 2% and N2O and O2 and ketamine if required. For adequate analgesia, fentanyl 2 μg/kg was administered. Proper suctioning was performed regularly. The mass was totally excised, and there was profuse bleeding when the mass was excised (around 50 ml), which was controlled and replaced with 50 ml of packed red cell transfusion. The patient's heart rate was 160–180 beats/min, and his saturation was 100% throughout the surgery. The operation lasted 40 min, and the mass was 10 × 5 × 5 cm in diameter ([Figure 2]). The patient was extubated when he was fully awake. The extubation process was smooth, and his recovery was uneventful. Postoperatively, the patient was maintained in the lateral position. There were no perioperative problems. The histological diagnosis was consistent with congenital teratoma.
Figure 1: The tongue teratoma.

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Figure 2: The mass after excision.

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  Discussion Top


Teratomas occur in one out of 4000 live births [3]. The occurrence of head and neck teratomas is generally localized to the neck and nasopharynx. It is reported that more than 90% of oral teratomas are diagnosed during the perinatal period. Ultrasonography is useful in prenatal diagnosis [4], particularly for oropharyngeal teratomas that interfere with fetal swallowing of amniotic fluid. Polyhydramnios is the most characteristic finding associated with fetuses with head and neck teratomas. In our case, no antenatal ultrasonography report was available; thus, the mass was detected only after delivery. When oral teratomas grow, they tend to protrude outside of the mouth, rather than posteriorly toward the oropharynx. In addition, children with oral teratomas have been reported to have associated anomalies including cleft palate [5], cystic hygroma, and other multifocal teratomas. In our case, no associated anomalies were found.

Airway control is most challenging in such patients. Upper airway difficulty causes anticipated functional problems at the hypopharynx [6]. Therefore, anesthesia should be planned accordingly to first secure the airway. Conventionally, fiberoptic nasal intubation would have been a better choice, but because of nonavailability of a pediatric scope preparations to surgically secure the airway were kept ready [7]. Along with difficult airway management, the importance of proper suctioning should also be kept in mind. In cases of anticipated difficult intubation with intraoral tumors, our goals of management should be careful assessment of the airway, provision for alternative emergency surgical airway, exclusion of any congenital lesions, check for laryngoscopy if possible, and establishment of a reliable airway with an appropriate induction agent [8]. In this case, check laryngoscopy could not be performed as the mass occupied a major working place for laryngoscopy.

Early resection is advised, especially for airway-obstructing teratomas. As an oral teratoma is well defined, complete excision is usually possible [9], as was accomplished in our case. Recurrences are rarely seen in head and neck teratomas.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Azizkhan RG, Haase GM, Apple baum H. Diagnosis, management and outcome of cervicofacial teratomas in neonates: a children's cancer group study. J Pediatr Surg 1995; 30:312–316.  Back to cited text no. 1
    
2.
Lopes MA, Pereira CM, da Cruz Perez DE, Vargas PA, de Almeida OP. Benign teratoma of the buccal mucosa in a 9-year-old girl: report of case and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 100:598–602.  Back to cited text no. 2
    
3.
Cay A, Bektas D, Imamoglu M, Bahadir O, Cobanoglu U, Sarihan H. Oral teratoma: a case report and literature review. Pediatr Surg Int 2004; 20:304–308.  Back to cited text no. 3
    
4.
Raveh E, Papsin BC, Farine D, Kelly EN, Forte V. The outcome after perinatal management of infants with potential airway obstruction. Int J Pediatr Otorhinolaryngol 1998; 46:207–214.  Back to cited text no. 4
    
5.
Becker S, Schön R, Gutwald R, Otten JE, Maier W, Hentschel R et al. A congenital teratoma with a cleft palate: report of a case. Br J Oral Maxillofac Surg 2007; 45:326–327.  Back to cited text no. 5
    
6.
Mishra SK, Kavitha J, Kumaravel S, Lalatendu KK. Anesthetic management of newborn for pedunculated teratoma of oral cavity. Anesth Essay Res 2010; 4:124–125.  Back to cited text no. 6
    
7.
Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult airway Society guidelines for management of the unanticipated difficult intubation. Anesthesia 2004; 59:675–694.  Back to cited text no. 7
    
8.
Ramani MN, Shah SK, Parikh U, Mehta P, Vakil SD. Infant with palatal swelling and anesthetic challenge. Indian J Anaesth 2002; 46:217–218.  Back to cited text no. 8
  Medknow Journal  
9.
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; 14:468–472.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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