Vallecular cyst in a newborn: a challenging airway.Vallecular cysts are an uncommon but well recognised cause of upper airway obstruction and death in newborns and infants. A two-day-old-male neonate, full term, 1.6 kg presented with noisy breathing and feeding difficulty since birth. On examination, he was tachypneic with intercostal retractions and inspiratory stridor. A contrast enhanced computed tomography scan Computed tomography scan (CT scan)A specialized type of x-ray imaging that uses highly focused and relatively low energy radiation to produce detailed two-dimensional images of soft tissue structures, particularly the brain. on the base of the skull/neck-T4 level showed a cystic lesion in the base of tongue base of tongue Surgical anatomy An area defined by the Am Joint Committee on Cancer, as extending from the line of the circumvallate papillae to the junction of the base of the epiglottis–valleculae, including the pharyngoepiglottis and glossoepiglottic folds measuring 12.8x10.3 mm. The child required intubation intubation /in·tu·ba·tion/ (in?too-ba´shun) the insertion of a tube into a body canal or hollow organ, as into the trachea. endotracheal intubation for laboured breathing in the nursery. The lesion was diagnosed as a vallecular cyst and planned for emergency radiofrequency ablation. Due to inability to ventilate through the in-situ endotracheal tube on arrival in the operating theatre, a decision was made to change the tube. The surgeons were asked to be on standby for emergency tracheostomy. After premedication premedication /pre·med·i·ca·tion/ (pre?med-i-ka´shun) 1. preliminary administration of a drug preceding a diagnostic, therapeutic, or surgical procedure, as an antibiotic or antianxiety agent. 2. with intravenous atropine, inhalational induction was carried out with 100% oxygen and 2 to 3% sevoflurane. Adequate mask ventilation could be achieved with hyperextension of the neck. Laryngoscopy with Miller size 0 blade revealed a large cyst obstructing the entire view. We managed to secure the airway with endotracheal tube size 2.5 using right paraglossal straight blade laryngoscopy with the aid of an intubating stylet stylet /sty·let/ (sti´lit) 1. a wire run through a catheter or cannula to render it stiff or to remove debris from its lumen. 2. a slender probe. sty·let n. 1. . Subsequent ventilation and anaesthesia were uncomplicated and the child was able to be extubated on the third postoperative day. Vallecular cysts usually present with stridor, feeding difficulties and respiratory distress as well as rarely, death caused by supraglottic obstruction due to mass effect (1). Preoperative assessment of these patients should include a careful history and a lateral neck X-ray (2). While computed tomography scan is helpful in delineating the cyst location and extent in relation to the base of the tongue, vallecula vallecula /val·lec·u·la/ (vah-lek´u-lah) pl. valle´culae [L.] a depression or furrow.vallec´ular vallecula cerebel´li and thyroid gland (3), it also helps to plan the optimal route of passage of the endotracheal tube or fibreoptic bronchoscope bronchoscope (brŏng`kəskōp'), long, tubular instrument with a light at the tip that is inserted through the windpipe and bronchial tubes to examine these structures. . The airway may be secured with direct laryngoscopy, paraglossal straight blade laryngoscopy, fibreoptic bronchoscopy or tracheostomy1. Even in experienced hands, direct laryngoscopy is fraught with dangers1. The review of various articles suggests that the use of paraglossal straight blade laryngoscopy, aided with an intubating stylet, will be most likely successful (4). A large-bore needle (18-gauge) with an attached syringe should be available if emergency aspiration is required. The surgeon should be on hand to intervene with emergency tracheotomy. [FIGURE 1 OMITTED] In conclusion, airway management of paediatric patients with vallecular cysts is challenging, with a high risk of total airway obstruction. We propose that awake fibreoptic intubation may be the preferred choice in experienced hands, but we reinforce the fact that even fibreoptic techniques may fail with the potential for loss of airway patency. We were able to secure the airway using right paraglossal straight blade laryngoscopy in this case and strongly recommend this technique for anaesthetists inexperienced with fibreoptic technique. References (1.) Gutierrez JP, Berkowitz RG, Robertson CF. Vallecular cysts in newborns and young infants. Pediatr Pulmonol 1999; 27:282-285. (2.) Ku AS. Vallecular cyst: report of four cases--one with coexisting laryngomalacia. J Laryngol Otol 2000; 114:224-226. (3.) Lev S, Lev MH. Imaging of cystic lesions. Radiol Clin North Am 2000; 38:1013-1027. (4.) Henderson JJ. The use of paraglossal straight blade laryngoscopy in difficult tracheal intubation. Anaesthesia 1997; 525:52-56. S. KALRA N. SARASWAT R. KAUR R. AGARWAL New Delhi, India |
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