LETTER TO EDITOR
Year : 2014 | Volume
| Issue : 2 | Page : 307-308
A large obstructive hard palate teratoma in a baby: Challenges to the anesthesiologist
Mugdha Markandeya, Rajesh Gore, Ujjwala Andurkar, Manisha Sapate
Department of Anaesthesiology, YCM Hospital, Sant Tukaram Nagar, Pimpri, Pune, Maharashtra, India
YCM Hospital, Sant Tukaram Nagar, Pimpri, Pune - 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||16-Apr-2014|
|How to cite this article:|
Markandeya M, Gore R, Andurkar U, Sapate M. A large obstructive hard palate teratoma in a baby: Challenges to the anesthesiologist. Saudi J Anaesth 2014;8:307-8
|How to cite this URL:|
Markandeya M, Gore R, Andurkar U, Sapate M. A large obstructive hard palate teratoma in a baby: Challenges to the anesthesiologist. Saudi J Anaesth [serial online] 2014 [cited 2019 Dec 7];8:307-8. Available from: http://www.saudija.org/text.asp?2014/8/2/307/130765
A 5 months old baby weighing 7 kg presented with pedunculated palatal mass since birth. It was a full term normal delivery. Prenatal diagnosis was not done. At birth, the swelling was small approximately the size of a lemon which rapidly progressed to the present size (as big as it's own head) within 5 months. The mother used to bottle-feed the baby by moving and holding the mass aside. CT scan revealed a large heterogeneous exophytic hypodense mass lesion arising from bony palate with fatty component and a tiny speck of calcification within suggestive of dermoid cyst/teratoma. No other congenital anomalies were present. The size of the mass was 20 × 13 × 10 cm, which weighed 1000 g after excision. The patient was scheduled for resection of the pedunculated mass under general anesthesia.
The baby was pale and hemoglobin was 8gm%. Other lab investigations were normal. On airway examination, the mouth opening was adequate with mass protruding out from the hard palate and adherent to the upper lip [Figure 1]. Difficult intubation was anticipated in view of large head, short neck and macroglossia in addition to the mass.  Tracheostomy tray was kept ready. Mask ventilation was impossible in this baby so oxygen was delivered by nasal canula. Laryngoscopy was very difficult as the mass was very heavy and it obstructed and compressed the airway in supine position so it was held up by an assistant. Hence we planned to excise the stalk of the mass under ketamine analgesia and immediately proceed with intubation. Precautions like continuous oxygenation, oral suctioning, head low position and monitoring of vital parameters were taken.
The patient was premedicated with Inj Atropine 0.01 mg/kg, Inj Ondensetron 0.1 mg/kg. Paracetamol suppository 20 mg/kg was kept. Induction was done with Inj Ketamine 1 mg/kg on spontaneous respiration. Oropharyngeal suctioning was done continuously and stalk was excised. Thus the mouth opened wide enough and laryngoscopy was possible. Inj Ketamine 10 mg IV was again repeated and the patient was intubated with a portex uncuffed 4.0 endotracheal tube in deep plane of anesthesia in the second attempt and throat was packed. Inj Atracurium 0.5 mg/kg was used as relaxant and the baby was maintained on O 2, N 2 O and Sevoflurane 0.8%. Heart rate was 160-180/min and saturation was 100% throughout the surgery. IV Kidral P was given according to 4:2:1 formula. Surgery was completely successfully and the patient was extubated after thorough suctioning and throat pack removal. Reversal given was Inj Neostigmine 0.5 mg/kg and Inj Glycopyrolate 8 mcg/kg. Extubation was smooth and recovery was uneventful. Post operatively, the patient was kept in lateral position.
Palatal teratoma is a benign congenital tumor with an incidence of 1:4000.  It is less than 10% in head and neck region and can be associated with other congenital anomalies like cleft palate, cystic hygroma, and other multifocal teratomas. Thus it is very important to search for other anomalies in such patients. Airway control is most challenging in such patients. Upper airway difficulty causes anticipated functional problems at hypopharynx.  Hence anesthesia should be planned accordingly to first secure the airway. In this case, check laryngoscopy could not be performed as the mass occupied a major working place of laryngoscopy. Conventionally, fibreoptic nasal intubation would have been a better choice, but due to non-availability of a pediatric scope, preparations for surgical airway were kept ready.  Along with difficult airway management, the importance of proper suctioning should also be kept in mind.
In cases of anticipated difficult intubation with intraoral tumor, our goals of management of such cases are careful assessment of airway, provision for alternative emergency surgical airway, exclusion of any congenital lesion, check laryngoscopy if possible and establishment of reliable airway with appropriate induction agent. 
| References|| |
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|3.||Mishra SK, Kavitha J, Kumaravel S, Lalatendu KK. Anesthetic management of newborn for pedunculated teratoma of oral cavity. Anesth Essay Res 2010:4:124-5. |
|4.||Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult airway Society guidelines for management of the unanticipated difficult intubation. Anesthesia 2004:59:675-94. |
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