Year : 2013  |  Volume : 16  |  Issue : 4  |  Page : 289--292

Posterior mediastinal mass: Do we need to worry much?


Parin Lalwani, Rajiv Chawla, Mritunjay Kumar, Akhilesh S Tomar, Padmalatha Raman 
 Department of Anaesthesia and Intensive Care, Govind Ballabh Pant Hospital, New Delhi, India

Correspondence Address:
Rajiv Chawla
Department of Anaesthesia and Intensive Care, Govind Ballabh Pant Hospital, New Delhi - 110 002
India

Abstract

Anesthetic management of mediastinal masses is challenging. There is abundant literature available on anesthesia management of anterior mediastinal mass. Anesthetic management of posterior mediastinal mass lesions normally have uneventful course. We describe airway collapse and difficult mechanical ventilation in the postoperative period in a patient with posterior mediastinal mass.



How to cite this article:
Lalwani P, Chawla R, Kumar M, Tomar AS, Raman P. Posterior mediastinal mass: Do we need to worry much?.Ann Card Anaesth 2013;16:289-292


How to cite this URL:
Lalwani P, Chawla R, Kumar M, Tomar AS, Raman P. Posterior mediastinal mass: Do we need to worry much?. Ann Card Anaesth [serial online] 2013 [cited 2021 Nov 27 ];16:289-292
Available from: https://www.annals.in/text.asp?2013/16/4/289/119183


Full Text

 Introduction



Airway management in patients with large mediastinal mass with or without the evidence of airway obstruction poses a challenge to the anesthesiologists. The literature regarding anesthetic concerns and perioperative care of patients with mediastinal mass has focused mostly on anterior mediastinal mass. Posterior mediastinal masses are traditionally considered to carry less anesthetic implications. [1],[2] However, as the tumor enlarges, it often occupies more than one compartment of mediastinum as there are no anatomical boundaries between mediastinal compartments. With increasing awareness of the risk of acute intra-operative airway obstruction in these patients, life threatening events occur less frequently in the operating room. However, in such patients, acute airway obstruction can occur in immediate post-operative period also. Therefore, vigilance must be maintained throughout the perioperative period. We report a case of posterior mediastinal mass, in whom postoperatively airway collapse occurred and mechanical ventilation became increasingly difficult; the patient was asymptomatic during the preoperative period.

 Case Report



A 23-year-old male presented with complaints of pain for 1-1/2 years and increasing weakness for 15 days in right upper and lower limbs. The patient had undergone balloon mitral valvotomy 2 years ago for mitral stenosis (MS). He also had grade 1 dyspnea, hoarseness of voice and non-radiating right sided chest pain since 6 months. There was no history of orthopnea, syncope, palpitation, non-productive cough, stridor or dysphagia. Physical and systemic examinations were unremarkable. Airway examination showed modified Mallampati grade 2 with restricted neck movements and adequate mouth opening. Hematological and biochemical examination results were within normal limits. Chest radiograph, postero-anterior view [Figure 1] showed homogenous mass in the upper zone of right lung and left tracheal deviation. Echocardiographic findings were mild to moderate MS, mild mitral and tricuspid regurgitation with normal left ventricle (LV) function. Contrast enhanced computed tomography revealed a right chest heterogeneous mass of the size 13 cm × 15 cm × 13 cm, extending into right side of neck and was crossing the midline. It was causing destruction of posterior ends of right second rib, T1, T2 vertebral bodies and their right side lamina and pedicles with intraspinal extension. Mass was also abutting and compressing the trachea, superior vena-cava, right main stem bronchus and esophagus [Figure 2]a and b. Magnetic resonance imaging showed right pre-paravertebral solid cystic mass with intra-spinal extradural component causing cord compression at C7and D1 level with vertebral body involvement at these levels. Tracheal and esophageal compression with anterolateral displacement was also evident. In view of increasing weakness of upper and lower limbs, the thoracic and neuro surgeons decided to perform spinal decompression first followed by excision of the remaining mass after 7 days.{Figure 1}{Figure 2}

On the day of surgery, patient was taken to operating room (OR) in supine position. Standard American Society of Anesthesiologists' monitors were placed. Difficult airway cart and flexible fiber-optic bronchoscope were kept ready. After securing venous access and arterial line and pre-oxygenation, anesthesia was induced with midazolam, fentanyl, and thiopentone. Easiness of bag and mask ventilation was confirmed, and thereafter, neuromuscular blockade was achieved with IV vecuronium. Trachea was successfully intubated with 8.5 mm ID endotracheal tube (ETT) using direct laryngoscopy. The laryngoscopy view was classified as Cormack Lehanne (CL) grade II. Anesthesia was maintained with O 2 , N 2 O and infusion of propofol and atracurium. Laminectomy was carried out at C7-D1 level in prone position and extradural component of the mass was excised by neurosurgeons. Intra-operative course remained uneventful. At the end of surgery patient was turned supine, neuromuscular block was reversed and after ensuring return of adequate spontaneous breathing and upper airway reflexes trachea was extubated. Patient was then shifted to post-operative recovery room. Five minutes later, patient became restless and had difficulty in breathing and stridor. In view of impending airway compromise, he was taken back to OR. Airway was secured with 8.5 mm ID cuffed ETT. At this time the CL Grade at laryngoscopy was grade-IV. Patient was electively put on mechanical ventilation for next 24 hour. Arterial blood gas analysis trends were within normal limits during this period. Next day, as the patient was conscious, generating sufficient tidal volume, and showed no signs of respiratory distress on T-piece trial of 1 hour; therefore, the trachea was extubated. One-hour post-extubation, patient developed difficulty in breathing and desaturation up to 60% in spite of O 2 supply by ventimask. Mask ventilation was attempted, which was found difficult. Direct laryngoscopy showed CL grade IV and he could be intubated only with a 7.5 mm ETT. Fiber-optic bronchoscopy was performed through ETT, which revealed tracheomalacia. In view of tracheomalacia, otorhinolaryngology consultation was obtained. The consultant advised to consult cardiothoracic vascular surgeon for the management of the mediastinal mass. The consultant considered that tracheostomy would not be useful till mediastinal mass is removed. The overnight arterial blood gas (ABG) showed persistently high PCO 2 (61.5-113 mmHg) and acidosis (PH 7.34-7.03), while PO 2 level was within normal limits (180-146 mmHg). It became increasingly difficult to ventilate the patient, the airway pressure increased precipitously. A repeat FOB through ETT showed increase in tracheal collapse.Next day, the patient was shifted to OR for emergency surgery. He underwent debulking of tumor via right postero-lateral thoracotomy, but superior margin was left in situ. He was electively ventilated for next 24 hour and then weaning with pressure support ventilation followed by T-piece trial was attempted, which failed as it resulted in CO 2 retention. In view of the possibility of necessity of prolonged ventilatory support tracheostomy was performed on 6 th postoperative day. Later, he developed pneumonia and sepsis and unfortunately succumbed 12 days after second surgery. The histopathology of the tumor reported it to be a grade IV malignant round cell tumor.

 Discussion



Mediastinal masses are known to be a nightmare for anesthesiologists. [3],[4],[5],[6],[7],[8] Its clinical presentations and associated problems depend on the size, location, and pathology of the mass and the thoracic structures affected by the mass. Posterior mediastinal masses predominantly produce effects on the spinal cord and rarely cause airway problem. In the present case, the patient presented with neurological manifestations, but he developed signs of acute airway obstruction in the immediate post-operative period. This is a rare instance where a posterior mediastinal mass caused progressive airway obstruction. This case demonstrates the need for cautious approach for posterior mediastinal masses. Compression of airway or cardiovascular structures in patients with mediastinal masses may be dependent on patient position and there may be dramatic improvement or deterioration after repositioning, [5],[6] therefore, it is important to know pre-operatively the position in which the patient is most comfortable and experiences least symptoms of airway obstruction. The present patient was not having any cardiovascular or respiratory problem in any position; and possibly because of prone positioning no such problems was encountered intra-operatively. Prolonged airway compression by the cervical or mediastinal mass may lead to precipitous airway collapse on establishing anesthesia or neuromuscular blockade. The airway obstruction can also manifest in the immediate post-operative period (over first 24 hr), as seen in this case when the patient developed stridor and respiratory distress. Béchard et al., [2] observed that, in patients with mediastinal mass, high risk of perioperative complications can be identified by the occurrence of cardiopulmonary signs and symptoms at presentation, combined obstructive and restrictive pattern on pulmonary function tests and tracheal compression > 50% and or pericardial effusion on CT scan. They reported incidence of intra operative cardiorespiratory complications as 4 of 105 (3.8%) and postoperative respiratory complications as 11/105 (10.5%) in such patients.

Several ventilatory management strategies have been suggested in patient undergoing surgery of mediastinal mass; however, cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation remain as last resort options. [3],[9],[10] Previous case reports have shown inability to ventilate using conventional modes of ventilation in both intra and postoperative period. In the present patient also postoperatively, ventilation became difficult over time while using SIMV mode. Alzeer et al., [11] used pressure-controlled mode successfully for a patient with large mediastinal mass having life threatening upper airway obstruction in post-operative period. Maintenance of spontaneous ventilation during anesthesia induction, immediate availability of the equipment's and manpower to establish CPB and carefully planned tracheal extubation are warranted for patients, who have posterior mediastinal mass with evidence of tracheobronchial compression.Standardized protocols and multidisciplinary team approach are vital for the perioperative care of patients with mediastinal masses. [5],[10] A pre-operative team discussion' instead of 'isolated consultations' might have improved the management and overall outcome in our patient. The perioperative physician should also be aware of the risk of cardiorespiratory compromise with posterior mediastinal mass as seen in anterior mediastinal mass and plan the anesthetic management accordingly.

References

1Datt V, Tempe DK. Airway management in patients with mediastinal masses. Indian J Anaesth 2005;49:344-52.
2Béchard P, Létourneau L, Lacasse Y, Côté D, Bussières JS. Perioperative cardiorespiratory complications in adults with mediastinal mass: Incidence and risk factors. Anesthesiology 2004;100:826-34.
3Tempe DK, Arya R, Dubey S, Khanna S, Tomar AS, Grover V, et al. Mediastinal mass resection: Femorofemoral cardiopulmonary bypass before induction of anesthesia in the management of airway obstruction. J Cardiothorac Vasc Anesth 2001;15:233-6.
4Tempe DK, Datt V, Virmani S, Tomar AS, Banarjee A, Goel S, et al. Aspiration of a cystic mediastinal mass as a method of relieving airway compression before definitive surgery. J Cardiothorac Vasc Anesth 2005;19:781-3.
5Erdös G, Tzanova I. Perioperative anaesthetic management of mediastinal mass in adults. Eur J Anaesthesiol 2009;26:627-32.
6Slinger P, Karsli C. Management of the patient with a large anterior mediastinal mass: Recurring myths. Curr Opin Anaesthesiol 2007;20:1-3.
7Slinger P. Management of the patient with a central airway obstruction. Saudi J Anaesth2011; 5:241-3.
8Sharma RK, Swain L, Dave N. Anaesthetic management of a patient with malignant mediastinal mass. Indian J Anaesth 2003;47:205-7.
9Wang G, Lin S, Yang L, Wang Z, Sun Z. Surgical management of tracheal compression caused by mediastinal goiter: Is extracorporeal circulation requisite? J Thorac Dis 2009;1:48-50.
10Anderson DM, Dimitrova GT, Awad H. Patient with posterior mediastinal mass requiring urgent cardiopulmonary bypass. Anesthesiology 2011;114:1488-93.
11Alzeer AH, Al-Otair HA, Mohammed M, Hajjar W, Ibraheim O. Acute hypoxaemia and right ventricular compression by a mediastinal mass. Internet J Anesthesiol 2007;14. Available from http://archive.ispub.com/journal/the-internet-journal-of-anesthesiology/volume-14-number-2/acute-hypoxaemia-and-right-ventricular-compression-by-a-mediastinal-mass.html#sthash.2wvjElSW.p1CGehvv.dpbs [Last accessed on 2013 Sept 2].