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Table of Contents
LETTER TO EDITOR  
Year : 2011  |  Volume : 14  |  Issue : 3  |  Page : 232-235
Anesthetic management for successful removal of intratracheal tumor


Department of Cardiac Anaesthesia, SMS Medical College and Attached Hospitals, JLN Marg, Jaipur, Rajasthan, India

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Date of Web Publication20-Aug-2011
 

How to cite this article:
Garg SK, Tiwari RL, Garg MK, Chaturvedi S. Anesthetic management for successful removal of intratracheal tumor. Ann Card Anaesth 2011;14:232-5

How to cite this URL:
Garg SK, Tiwari RL, Garg MK, Chaturvedi S. Anesthetic management for successful removal of intratracheal tumor. Ann Card Anaesth [serial online] 2011 [cited 2019 Jul 16];14:232-5. Available from: http://www.annals.in/text.asp?2011/14/3/232/84034


The Editor,

Primary tracheal masses are very rare and are mostly malignant, occurring in 0.2 per 1,00,000 persons per year. [1] These patients can be mistaken as having asthma and require treatment with inhaled corticosteroids and beta 2 -agonists. [2] They are usually treated for many years as asthma or chronic obstructive pulmonary disease (COPD), unless a surgeon advises a computed tomography (CT) scan or does some endoscopic procedure to rule out any intratracheal mass and, surprisingly, finds an intratracheal mass responsible for the symptoms. [3] They usually become symptomatic when they start obstructing more than 75% of the tracheal lumen. Tracheal mass present at a lower level can have more complicated management of airway, anesthesia and the surgery for successful and safe removal of the mass. [3]

Intratracheal tumors are usually challenging to the anesthesiologists because of the difficulty in establishing a patent airway before the commencement of surgery. The principal anesthetic consideration is ventilation and oxygenation in the face of an open airway. Ventilation can be managed in different ways, including manual oxygen jet ventilation, high-frequency jet ventilation, distal tracheal intubation, tracheostomy, spontaneous ventilation and cardiopulmonary bypass (CPB). [4]

We report here the anesthetic management for successful removal of an intratracheal tumor, which allowed the early extubation and rapid recovery of the patient with shorter stay in the intensive care unit.

A 55-year-old male presented to the cardio thoracic and vascular surgery (CTVS) Department of our hospital with symptoms of severe orthopnea, which had gradually progressed over a period of 1 year and worsened over the last 2 months. The patient was treated as a case of COPD for the last 1 year, which partially relieved patient's symptoms. There was no significant past history. His pulse rate, blood pressure and respiratory rate were 110/min, 130/90 mmHg and 32/min, respectively. On examination, no growth or lymph nodes were palpable externally in the submandibular region. The patient had signs of respiratory distress. There were over activities of sternocleidomastoid and alar nasi muscles. On austcultation, inspiratory stridor was noted. Routine blood investigations and chest radiograph was unremarkable.

Indirect laryngoscopic examination was normal. His SpO2 and PaO 2 were 90% and 78 mmHg, respectively on room air. CT scan of the neck [Figure 1] revealed a pedunculated mass of about 3 cm × 2 cm in the trachea at the level of the 6 th and 7 th cervical vertebra (C 6, 7 ), which was completely occluding the tracheal lumen on lying down, and there was only a slit-like lumen in the propped up position. There was no pulmonary metastasis. Rigid broncoscopy was not possible as the patient was unable to lie down and facility for flexible broncoscopy was not available at that time. Trucut biopsy was not taken as the patient's condition did not allow us to do this; therefore, a preoperative diagnosis of benign or malignant tumor could not be made.
Figure 1: Preoperative computed tomography scan of the neck showing near-complete occlusion of the trachea by the tumor. The arrow indicates the site of the tracheal mass

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The CTVS surgeons planned a surgical excision of the tumor. Consent for surgery and anesthesia was taken intravenous cannula, arterial cannula were inserted. Electrocardiogram and pulse oxymetry measurements commenced. CPB circuitry and machine were kept in readiness.

A low tracheostomy (just above the sternal notch) was performed with a collar incision under local anesthesia in the propped-up position and a cuffed tracheostomy tube of no. 7.5 was inserted. The patient was positioned supine. Glycopyrrolate, 0.005 mg/kg, midazolam 0.4 mg/kg and fentanyl 1.2 mcg/kg were administered intravenously prior to induction of general anesthesia. General anesthesia was induced by intravenous propofol 2 mg/kg and 2 mg/kg of suxamethonium. While the patient was ventilated via the tracheostomy tube with an equal mixture of oxygen and nitrous oxide and 0.2 to 1 % of isoflurane, bronchoscopy with a rigid bronchoscope was performed. Since the tumor was not vascular, chunks of the tumor tissue was exciced; this allowed a good passage in the tracheal lumen, which allowed us to insert a 6.5 mm endotracheal tube. While this was inserted, the tracheostomy tube was removed. The tube was passed beyond the site of the tumor. The patient was mechanically ventilated facilitated by vecuronium and isoflurane 0.2 to 1%. There was little resistance in ventilating the patient with a small endotracheal tube, but there were no significantly changes in the arterial blood gas level. The tumor stalk was visible through the tracheostomy site and was attached about 1 cm above the stoma on the left lateral wall of the trachea. The remainder of the tumor was removed through the tracheostomy stoma and the local area was electro-coagulated. There was around 250 ml of blood loss, which was replaced with crystalloids solution. There was no need of intraoperative blood transfusion. Hemostasis was secured and the endotracheal tube was replaced with a cuffed endotracheal tube no. 8.5. The tracheostomy site was primarily closed. The tracheostomy site was checked for the presence of any air leak by welling it with water. The wound was closed in layers. The patient remained hemodynamically stable throughout the procedure. The neck of the patient was then flexed and tucked in that position with the help of thick silk sutures. The patient was extubated in the Intensive Care Unit at 2 h as his ABG was showing PO 2 of 98 mm Hg and his chest radiograph was normal and he was maintaining 100% SpO 2 on room air.

The patient became completely asymptomatic and his orhtopnea disappeared. The patient had an uneventful postoperative course. Histopathological examination of the tumor segments revealed presence of an adenoid cystic carcinoma. The patient was discharged after 8 days and referred for radiotherapy. Follow-up CT scan after 1 month showed no residual or recurrent tumor and nice patent trachea. Also, there were no associated pulmonary metastases.

Primary intratracheal tumors are very rare and are usually malignant. By far, the most common of these are squamous cell carcinoma, followed by adenoid cystic carcinoma (cylindroma). Cylindroma is a slow-growing tumor, which mainly involves the salivary glands, and its occurrence in the lower respiratory tract is low (0.1% of all bronchopulmonary neoplasms). [5] The presence of a tracheal tumor is often missed due to the unapparent progression of nonspecific respiratory symptoms, resulting in frequent misdiagnoses as asthma with acute exacerbations, bronchitis and recurrent pneumonias.

The management of anesthesia for tracheal surgery presents many challenges to the anesthesiologist, such as difficult airway management and ventilation of the patient. Knowledge of the various techniques for airway management is crucial. Meticulous planning and communication between the anesthetist and the surgical team is mandatory for the safe and successful outcome of surgery for patients undergoing this procedure.

The most challenging problem in such cases arises due to difficulty in establishing a patent airway as well as space for operation. Simultaneously, there is a need to control the seepage of blood and small chunks of tumor tissue distally into the tracheobronchial tree while resecting the primary tumor.

There may be total obstruction of airway when ventilation attempts via mask using positive pressure is performed because airway obstruction has both a fixed and a dynamic component. In a study by Theroux et al., spontaneously breathing children could maintain ventilation but they exhibited total obstruction when ventilation was attempted via mask using positive pressure. [6] The possibility of encounter obstruction to ventilation after the trachea has been intubated was also kept because papillomas can be "shaved off," filling the endotracheal tube lumen. [6]

High-frequency jet ventilation with a small bore catheter can increase the airway obstruction by movement of the mass itself and can prevent the exhalation. [7] Further, in jet ventilation, there can be a compromise of oxygenation by collapse of the tracheal lumen distal to the mass during expiration or by development of subcutaneous emphysema and pneumothorax. [8]

We avoided the CPB along with systemic heparinisation because of the associated problems. [9]

Because in our case the tumor was located in the mid-trachea (C 6, 7 ), we planned a low-primary tracheostomy (just above the sternal notch) under local anesthesia to achieve our goals with the patient in the propped-up position before induction as the patient was unable to lie down even for short periods of time. This gave us an access to the patent airway and hence the patient could be now anesthetized with routine induction agents with the availability of good plane of anesthesia.

This approach is suitable mostly for pedunculated, nonvascular intratracheal tumor situated in the cervical region. Tumors that are situated beyond the sternal notch would not allow a successful tracheostomy as tracheal intubation and tracheotomy increase the risk of the disease spreading to the trachea and bronchi. Use of collar incision for resection of the tracheal tumor has been recommended. [10]

Because the peduncle could not be seen through the bronchoscope and leaving a part of the tumor in the tracheal wall behind, it was not planned to resect the tumor completely by using the bronchoscope.
"Resection and reconstruction of the trachea" has been described as the treatment of choice, but this is associated with a high expertise of mobilizing the tracheal tissue and with the postoperative risk of tracheal dehiscence and tracheal stenosis along with the morbidity associated with prolonged ventilation and longer staying in the Intensive Care Unit. [3]

Laser excision using a Nd YAG laser and Potassium Titanic Phosphate (KTP) laser for primary ablation of the tumor and use of endoscopic procedure as primary modality of treatment of the tumor has also been described. [11] However, facility of laser ablation was not available at our center.

Radiotherapy is considered an ineffective primary treatment of malignant tracheal tumors. [12] Postoperative adjuvant radiotherapy after tracheal surgery is associated with a good long-term survival rate. [13] We referred our patient postoperatively for radiotherapy.

We therefore like to convey through this case report that it is of utmost importance to secure a patent airway before embarking upon any surgical procedure in intratracheal tumors. Further, this case report reiterates that bronchoscopy and open surgical procedures go hand in hand in the successful management of such cervical intratracheal tumors. A well-planned tracheostomy and rigid bronchoscopy can help in resection of the intratracheal tumor through the tracheostomy site along with achieving the goals of securing a patent airway. This approach avoids the use of sternotomy and CPB along with the unsightly scar and its attendant complications. Further, early extubation of the patient allows a less-morbid postoperative period as the postoperative ventilation is avoided. Postoperative recovery could be quick, smooth and uneventful.

 
   References Top

1.Azar T, Abdul-Karim FW, Tucker HM. Adenoid cystic carcinoma of the trachea. Laryngoscope 1998;108:1297-300.  Back to cited text no. 1
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2.Jones TM, Alderson D, Sheard JD, Swift AC. Tracheal paraganglioma: A diagnostic dilemma culminating in a complex airway management problem. J Laryngol Otol 2001;115:747-9.  Back to cited text no. 2
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3.Azorin J, Lamberto JF, Personne C, Larmignat P, Khellaf M, Kmeny JL, et al. Adenoid cystic carcinoma of the trachea: Treatment by combined laser therapy and surgery. Rev Mal Respir 1987;4:95-6.  Back to cited text no. 3
    
4.Pinsonneault C, Fortier J, Donati F. Tracheal resection and reconstruction. Can J Anaesth 1999;46:439-55.  Back to cited text no. 4
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5.Blanco Orozco Al, Ginel Canamaque A, Sanchez Navarro JM, Torres Cansino M. Adenoid cystic carcinoma of respiratory airways: Course and treatment. Arch Bronconeumol 1999;35:257-60.  Back to cited text no. 5
    
6.Theroux MC, Grodecki V, Reilly JS, Kettrick RG. Juvenile laryngeal papillomatosis: Scary anaesthetic. Paediatr Anaesth 1998;8:357-61.  Back to cited text no. 6
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7.Cook TM, Bigwood B, Cranshaw J. A complication of transtracheal jet ventilation and use of the aintree intubation catheter during airway resuscitation: A case report. Anaesthesia 2006;61:692.  Back to cited text no. 7
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8.Bourgain J L, Desruenne E, Fischler M, Ravussin P. Transtracheal high frequency jet ventilation for endoscopic airway surgery: A multicentre study. Br J Anaesth 2001;87:870-5.  Back to cited text no. 8
    
9.Michael Belmont J, Mark Wax K, Fructose Desouza N. The difficult airway: Cardio pulmonary bypass - the ultimate solution. Head Neck 1998;20:266-9.  Back to cited text no. 9
    
10.Pearson FG, Todd TR, Cooper JD. Experience with primary neoplasms of the trachea and carina. J Thorac Cardiovasc Surg 1984;88:511-8.  Back to cited text no. 10
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11.Mikkelsen PG. Laryngeal papillomatosis with airway obstruction in an infant. Acta Anaesthesiol Scand 2001;45:645-8.  Back to cited text no. 11
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12.Cheung AY. Radiotherapy for primary carcinoma of trachea. Radiother Oncol 1989;14:279-85.  Back to cited text no. 12
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13.Maziak DE, Todd TR, Shafique H, Keshavjee, Winton TL, Van Nostrand P, et al. Adenoid cystic carcinoma of airway: Thirty two year experience. J Thorac Cardiovasc Surg 1996;112:1522-32.  Back to cited text no. 13
    

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Correspondence Address:
Suneel Kumar Garg
Department of Critical Care and Emergency Medicine, ICU, 4th Floor, Super-Speciality and Research Block, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi - 110 060
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.84034

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