2024 FSA Podium and Poster Abstracts
P012: MANAGEMENT OF DIFFICULT AIRWAY AND RESECTION OF LARGE JUVENILE NASOPHARYNGEAL ADENOMA
Kristina Ruiz, MD1; Lindsey J Laux, MD1; Hannah Tuckwell, MD2; Micheal Armstrong, MD1; Yehuda Raveh, MD1; Madison Rhodes, DO2; 1Jackson Memorial Hospital; 2Nicklaus Childrens Hospital
The patient is a 12 year old 35 kilogram male who presented from home to the Emergency Department with complaints of weight loss, recurrent nosebleeds, difficulty swallowing, progressive muffled voice and worsening apneic episodes while sleeping. Physical exam and CT scan revealed a large nasopharyngeal tumor with extension into the skull base, oropharynx, and soft palate, causing nearly complete obliteration of the airway on maximal mouth opening. The patient was admitted to the PICU for airway monitoring and supplemental oxygen via facemask. ENT concluded an assumed preliminary diagnosis of juvenile nasopharyngeal adenoma.
After multidisciplinary discussion between Pediatric Anesthesia, Pediatric ENT, and IR, the plan for controlled intubation followed by IR embolization and surgical resection with ENT. Patient was brought to the OR for awake oropharyngeal intubation with ENT present for possible surgical airway if intubation was unsuccessful. Decision was made to proceed with awake intubation given patient cooperation with appropriate mouth opening. Ability to maintain spontaneous ventilation was imperative in airway management given complete obstruction of nasopharynx due to tumor. Induction of general anesthesia with loss of pharyngeal tone would lead to loss of airway and inability to mask ventilate. Video laryngoscopy with D blade was used as well as 4 mm flexible scope on the second screen. Laryngoscope was advanced until it was just superior to the epiglottis, then the scope was advanced with lidocaine administration at vocal cords. Flexible scope was advanced past vocal cords and an induction dose of propofol was given. Airway was secured with ETT with one attempt and no desaturations.
Upon intubation, the patient was to be transferred to the IR suite for embolization. Patient transferred to the PICU for 48 hours prior to surgical resection. No difficulty with ventilation on minimal ventilatory support.
Patient returned to OR for resection with ENT. Upon arrival, the patient had a PICC line in place. Large bore IV access was obtained, with two 16 gauge peripheral IV, one of which was exchanged for a 7 French rapid infusion catheter for intraoperative resuscitation. Arterial line placed with serial ABG and TEG obtained to guide blood product administration, Starting hematocrit was 24 with 4 pRBCs, 4 FFP, 1 cryoprecipitate and 1 platelet given intraoperatively, estimated blood loss three liters. Brief infusion of vasopressin and phenylephrine required intraoperatively.
Post procedure the patient had no pressor requirements or transfusion needed. Patient was extubated on post operative day two and discharged on postoperative day six.