Year : 2014  |  Volume : 17  |  Issue : 1  |  Page : 73--74

Authors' reply

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

How to cite this article:
Lalwani P, Chawla R, Kumar M, Tomar AS, Raman P. Authors' reply.Ann Card Anaesth 2014;17:73-74

How to cite this URL:
Lalwani P, Chawla R, Kumar M, Tomar AS, Raman P. Authors' reply. Ann Card Anaesth [serial online] 2014 [cited 2021 Jan 16 ];17:73-74
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Full Text

The Editor,

We thank Singha et al. [1] for their interest in our article, "Posterior mediastinal mass: Do we need to worry much" [2] and making constructive comments. It is agreed that, cervicothoracic sign, a variant of silhouette sign, which can be seen in lesions of apical segments of upper lobes, pleura, or posterior mediastinum, [3] was indeed positive, as can be seen in the chest X-ray shown in the referred article. The compression on the vertebral body and intraspinal extension of the mass was seen in the computed tomography scans and was further confirmed by magnetic resonance imaging. These images were not shown in the referred article but these findings were confirmed by a senior radiologist of our institute. Decision for two-stage surgery was taken after multidisciplinary team discussion, which included the operating neuro-surgeon and the cardiothoracic surgeon. The team opined that spinal cord compression in the context of deteriorating neurological function represents a neurosurgical emergency.

The mass was abutting the trachea and the right main bronchus causing their displacement and some degree of compression but as evident in coronal view of contrast enhanced computed tomography chest shown in the article, air luminogram was maintained. Considering insignificant external compression and absence of any airway compressive symptoms in both supine position and during sleep, normal routine anesthesia management including induction was carried out in this patient. It is agreed that in the present case with a history of mass for more than 1 year, anesthesia induction, propofol infusion, long duration of surgery (5 hours) in prone position may all have contributed to the airway compromise that followed the tracheal extubation after the surgery. In retrospect, it is clear that presence of airway compression/displacement on imaging and/or the symptoms of airway compromise in presence of posterior mediastinal mass should not be taken lightly. In such cases interdisciplinary team discussion (anesthesiology, surgery, radiology, pathology and otolaryngology), clinical assessment, careful planning and vigilance is required. A lack of symptoms in the pre-operative evaluation in such patients, does not guarantee an uneventful anesthetic course and all the necessary arrangements including rigid bronchoscope and cardiopulmonary bypass should be made depending upon the severity and involvement to prevent airway catastrophe.


1Singha S, Bodhey N. In response to "posterior mediastinal mass: Do we need to worry much?" Ann Card Anaesth 2014;17:73-5.
2Lalwani P, Chawla R, Kumar M, Tomar AS, Raman P. Posterior mediastinal mass: Do we need to worry much? Ann Card Anaesth 2013;16:289-92.
3Kazerooni EA, Gross BH. Cardiopulmonary Imaging. Philadelphia, PA. Lippincott Williams & Wilkins; 2004. p. 206.