H Prabhakar, L Kumar, G Rath
H Prabhakar, L Kumar, G Rath. Difficult Airway Due To Large Scalp Swelling In Occipital Region. The Internet Journal of Anesthesiology. 2006 Volume 11 Number 2.
To the Editor,
A 24-year-old male presented with a big scalp swelling in the occipital region since birth, which was initially small and increased to present size of 15×10×7 cm. The swelling was lobulated, non-mobile, non-tender, with normal skin temperature and of different consistency. There was no discharge from the swelling. The aspirate from the swelling showed features of mesenchymal tumor of pleomorphic type.
A magnetic resonance imaging revealed a large well circumscribed lesion in left occipital region. The mass had predominant isointense signal on T1 weighted image with central portion of lesion showing increased signal on T1 weighted and heterogenous signal on T2 weighted image. On contrast the lesion showed intense enhancement except central part suggestive of necrosis. The occipital bone was destroyed. The mass also had extradural extension.
The patient posed anesthetic challenge primarily in two aspects. The maintenance of airway and intubation were primary concern. Subsequently, central venous cannulation of internal jugular vein or subclavian vein was likely to be difficult. As the patient had difficulty in lying supine, intubation in lateral position was planned. Awake fibreoptic intubation or intubating laryngeal mask airway (ILMA) were possible safe options. The patient however refused awake fibreoptic intubation and requested intubation after general anesthesia.
We decided to perform direct laryngoscopy for intubation after general anesthesia. Simultaneously, all equipments for difficult and failed intubation were kept ready at hand. The intubation in left lateral position was successfully done in less than 10 seconds with little manipulations. With the patient in same position, right subclavian vein was cannulated with double lumen central venous catheter.
We are not aware of any patient with such a large swelling in the occipital region. Intubation in lateral position has been studied by some authors.1,2,3 Failure of airway management occurred often with tracheal tube insertion. Laryngeal masks and ILMA are suggested methods for airway maintenance.
Dr. Hemanshu Prabhakar Department of Neuroanaesthesiology All India Institute of Medical Sciences, New Delhi-110029 India E-mail: firstname.lastname@example.org Fax: +91-11-26862663 Phone: +91-9868398205