2025 FSA Podium and Poster Abstracts

Introduction/Background: 12-year-old male with history of asthma, environmental allergies, and recent diagnosis of juvenile nasopharyngeal angiofibroma presented for MRI of brain, face, and neck under general anesthesia. The patient had been experiencing four to five months of spontaneously resolving bilateral epistaxis, dysphagia, orthopnea, OSA and difficulty eating with weight loss. Endoscopy performed by ENT revealed a highly vascular mass in the right nare between the septum and middle turbinate protruding into the oropharynx. A previous MRI revealed a patent trachea and hypopharynx but needed repeating for pre-operative surgical planning as the patient was unable to lie flat and keep still.

Methods: The anesthetic plan: asleep fiberoptic intubation, discussed with the patient and parents, with ENT team/OR team on standby. The patient did not receive premedication. after adequate preoxygenation, co-induction with sevoflurane, glycopyrrolate, lidocaine, propofol, dexmedetomidine occurred in the induction room outside of Zone IV of MRI. After easy bag-mask ventilation was confirmed, rocuronium was administered. The fiberoptic bronchoscope passed smoothly through the vocal cords with visualization of the carina, and a standard 6.0 endotracheal tube passed atraumatically. Chest rise, bilateral breath sounds, and capnography were observed. Of note, a C-MAC was on standby. A second 18g peripheral IV was placed in view of potential for bleeding from tumor. The patient was transported to MRI on a stretcher with manual ventilation. He was transported with EKG, noninvasive blood pressure, and pulse oximeter in place. During this time, the patient remained hemodynamically stable. Patient was connected to ventilator after arriving in Zone IV. After completion of imaging, the patient was transported back to the induction room and received additional dexamethasone, ondansetron, and glycopyrrolate prior to extubation, sufficient reversal of neuromuscular blockade via a peripheral nerve stimulator was observed; a reversal agent was not administered for more than three hours between the last dose of NMB and time for extubation. Patient was extubated sat up in stretcher with a Cook 14-French exchanger in place, which remained for ten minutes post-extubation to ensure airway patency upon emergence, then removed after the patient returned to his baseline airway status and transported to PACU.

Results: The patient recovered well without airway difficulties. MRI revealed a large mass in the nasopharynx with peripheral extension, including intracranially towards the right parasellar region. He later underwent mass embolization followed by mass resection. He was discharged a few days later with follow-up MRI, which revealed no pathologic enhancement.

Discussion: Factors to consider in the planning for this case included an anticipated difficult airway with a large, extensive, highly vascular tumor with risk of bleeding in the setting of a difficulty airway with potential complications with ventilation, intubation, and extubation. Procedure was also performed off-site NORA setting, which is challenging for a difficult airway, highlighting the importance of multi-disciplinary team approach. Asleep intubation versus awake intubation was another factor to consider. Lastly, a Cook catheter was implemented as a safety instrument if the patient did not meet extubation criteria and needed re-intubation.