Paediatric Anaesthesia 1999 9: 439–443

Case report
Anaesthetic management of an infant with
anterior mediastinal mass
LAKSHMI VAS, FALGUNI NAREGAL AND VEENA NAIK
Bai Jerbai Wadia Hospital for Children, Acharya Donde Marg, Parel Bombay 400, India

Summary
A substantial mediastinal mass in a small infant can create a
dilemma regarding the safest mode of airway management. To
ensure safety at all times, we adopted one lung ventilation for fear
of compression of the carina and/or both main bronchi. Anaesthesia
was maintained at a very light plane by the use of local nerve
blocks to secure the airway and epidural analgesia for surgery until
the tumour was moblized.

Keywords: mediastinal mass; airways obstruction

Introduction Case report

Anaesthesia for surgery of an anterior mediastinal
mass is a challenge for cardiorespiratory and airway
management in the perioperative period. Reports
(1–15) of anterior mediastinal masses in paediatrics
address these problems mostly in older children. In
one review (9), the age of the patients varied from
1 day to 18 years, but children with serious airway
problems requiring general anaesthesia were aged
more than 5 years. In infants and small children not
only are the airways more compressible, but also
small decreases in airway diameter cause relatively
larger decreases in tracheal lumen and increased
airway resistance (9) We present a case of anterior
mediastinal mass in a 2-month-old infant where the
problems were magnified by the small size of the
patient with a relatively large tumour. To ensure a
patent airway, we initially had to resort to
endobronchial intubation and one lung ventilation.
Only after control of the mass was achieved could
we make the tube tracheal to ventilate both the lungs.
Correspondence to: L. Vas, Bai Jerbai Wadia Hospital for Children,
Acharya Donde Marg, Parel Bombay 400, India.
The patient was a 2-month-old infant weighing 3.9
KG. He was born prematurely at 34 weeks. The
parents gave a history of excessive crying, cough and
breathlessness, especially during feeds, from the time
of birth. This was unrelieved by a short course of
steroids, bronchodilators and chest physiotherapy.
At the time of preanaesthetic examination, the patient
was tachypnoeic with a respiratory rate of 55·min−1.
There was no air entry in the right upper and mid
zones and there were obstructive sounds in the right
lower zone. There was no deterioration of the patient
in the supine position as seen by his continued
activity, as well as ability to go to sleep in this position.
Clinically there were no signs of compression of
the superior vena cava.
Chest X-ray (Figure 1) showed a mediastinal mass
occupying the right upper half of the chest and
extending to the left side. The mediastinal mass ratio
of width of the mass to intrathoracic width at the
level of diaphragm was 0.526. The left lung was
emphysematous. The trachea was shifted to the right
as were the rest of the mediastinal structures. Only
the right lower lobe could be visualized. The trachea

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440 L. VAS ET AL.
Figure 1
Mediastinal mass occupying most of the right half of the chest.
was compressed to 75% of its diameter by the tumour
as compared with the diameter of the noncompressed
part of trachea. This compression extended down
to the bifurcation and just beyond. (Figure 2). The
obstruction of the right bronchus is not very clear in
this picture but in the larger radiograph and the
various plates of the computed tomography (CT)
scan, it was clearly seen.
The contrast enhanced CT scan showed a cystic
mass with multiple septa and calcification,
compressing the trachea and the right bronchus.
Figure 3 shows this compression of trachea. Two-
dimensional echo delineated the mass to be extra
cardiac overlying the heart superiorly and anteriorly
but the pulmonary vessels and aorta were normal.
The arterial pH was 7.341, PCO2 5.16 kPa
(38.8 mmHg), PO2 5.14 kPa (38.7 mmHg), when the
patient was breathing air. The tumour was presumed
to be a teratoma due to its midline position in the
anterior mediastinum and calcification. The tumour
markers such as alpha-feto protein and beta human
chorionic gonadotrophin were normal. VMA levels
were also normal. The child was considered for
excision of the circumscribed well defined mass.
Intraoperative management
When the infant was taken for anaesthesia he
appeared to be even more breathless than usual. The
Figure 2
The mass causing gross compression of trachea and right bronchus.
SpO2 on air was 89%. He was preoxygenated and
inhalational anaesthesia was induced with oxygen
and halothane 1% and gradually nitrous oxide
introduced with a rigid 3-mm brochoscope ready
for use. Within a few minutes, he was sufficiently
anaesthetized to allow the mouth and throat to be
sprayed with lignocaine. Bilateral superior laryngeal
blocks, and then bilateral glossopharyngeal blocks
were performed. Subsequently, anaesthesia was
continued with oxygen and 1%-0.5% halothane and
laryngoscopy was easily performed. A 3-mm
armoured tube was passed into the right main
bronchus using a stilette curved slightly to the right
and passing the tube as far down as it would go.
This was confirmed by absence of air entry on the
left side but breath sounds on the right side including
the upper and middle lobes. An intraarterial and
central venous line from the right femoral artery and
vein were then placed under deeper anaesthesia.
The infant was turned on his side, after confirming
that we could maintain normal vital signs and blood
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 MANAGEMENT OF AN INFANT WITH ANTERIOR MEDIASTINAL MASS
gases with one lung ventilation. A 19-G Touhy needle
(Portex Hythe, Kent) was introduced into the L3–4
interspace to pass an open ended epidural catheter
to the T5 level and 1.5 ml of 0.25% bupivacaine were
injected.
Anaesthesia was continued with halothane 1% in
oxygen with intermittent assistance to spontaneous
ventilation. The chest was opened by median
sternotomy and the whole tumour visualized. Only
then was the patient paralysed with atracurium for
intermittent positive-pressure ventilation, the
endobronchial tube withdrawn into the trachea and
both lungs ventilated. The SpO2, PeCO2 and
electrocardiogram remained within normal limits.
The time for induction of anaesthesia, placement of
various lines and epidural catheter until opening of
the chest was 65 min. After paralysis, the pressure
necessary to maintain a tidal volume of 8 ml·kg−1
required to be increased. During dissection, the
airway pressure varied erratically, up to a high of
80 cmH2O. On four occasions surgery had to be
stopped temporarily to allow ventilation, with the
surgeon holding the tumour away from the trachea,
especially when the posterior aspect of the tumour
was being dissected. The tumour was found to be
overlying a substantial segment of the left and right
main bronchi. The blood loss of 450 ml was replaced
with blood and 50 ml of fresh frozen plasma. The
pulse varied between 130·min−1 and 150·min−1 and
the direct systolic arterial pressure between 90 and
 1999 Blackwell Science Ltd, Paediatric Anaesthesia, 9, 439–443
441
Figure 3
Computed tomography showing
the mass compressing the
trachea.
50 mmHg. The pH varied between 7.2 and 7.4, PCO2
5.32–8.22 kPa (40–61 mmHg), PO2 6.25–19.01 kPa
(47–140 mmHg) with 0.6–1 FiO2. Once the tumour
was removed, the airway pressures could be reduced
to 25–30 cmH2O. After surgery and reversal of
neuromuscular blockade, the oxygen and CO2 were
well maintained. The child appeared to be quite
comfortable and pain-free but still had tachypnoea.
The armoured tracheal tube was left in situ overnight,
because there was an anxiety that any postoperative
swelling around the airway could potentially occlude
it. He required sedation with midazolam 0.05.kg−1
intravenously to retain the tube and as the ventilation
was adequate with normal blood gases in air, we
preferred to leave him breathing spontaneously in
0.3 FiO2 rather than ventilate him which would entail
paralysis and further sedation. Eighteen hours
postoperatively, when his condition had stabilized,
with normal blood gas values, he was extubated.
Anti inflammatory agents diclofenac 1 mg·kg−1
intramusculary initially and later nimusulide 5 mg
twice daily via the Ryle’s tube and hydrocortisone
were also given.
He continued to receive epidural analgesia with
1 ml of 0.125%. bupivacaine 6 hourly for 3 days. The
histopathology revealed the tumour to be a well
differentiated teratoma. The patient is presently
normal with no recurrence of the tumour 18 months
after surgery.
442 L. VAS ET AL.
Discussion
A mediastinal mass can produce intrathoracic
compromise by extrinsic compression of the
tracheobronchial tree, superior vena cava or right
ventricular outflow. The cardiac output may also be
diminished due to pressure on the great vessels by
the tumour, negative inotropic effects of anaesthetic
agents, diminished venous return associated with
diaphragmatic paralysis and positive pressure
ventilation. These features of cardiopulmonary
vulnerability may make induction of anaesthesia very
hazardous. During anaesthesia, the tumour,
supported by muscle tone in an awake patient
descends by its weight on to the large airways
rendered compressible by relaxation of their smooth
muscle (9,16). The airways also lose the distensive
effect of normal transpleural gradient, the tethering
effect of expanded lungs by a reduction in inspiratory
muscle tone and an increase in abdominal muscle
tone. Tracheal narrowing greater than 35% increases
the risk of airway obstruction during general
anaesthesia (9).
Most reports consider general anaesthesia as the
last resort, preferably after radiotherapy, chemo-
therapy and steroids. However, one report (13)
where paediatric cancer patients received general
anaesthesia irrespective of cardiorespiratory
symptoms suggested that the most important factors
in preventing anaesthetic complications is
anticipation of airway problems.
Our choice of technique was limited by the age of
the infant. There was no apparent compression of
pulmonary vessels but there was gross compression
of the intrathoracic trachea and right bronchus. The
left bronchus appeared to be normal with the infant
awake but we had no way of predicting whether it
would get compressed by the overlying tumour
under general anaesthesia. We used nitrous oxide as
a calculated risk to avoid the negative inotropic
effects of a higher concentration of halothane.
Our decision to use the right side for one lung
ventilation in view of the collapsed upper and middle
lobes may seem unwise and could be criticized.
We did not want to keep the tube tracheal with a
possibility of carinal and/or both right and left main
bronchial obstruction. Nor could we afford to subject
the child to any prolonged manoeuvres in an attempt
to intubate the left bronchus especially with the
possibility of loss of the airway at any moment. We
chose the right side because right bronchial
intubation is easier, and in case of compression of
trachea and both bronchi, at least the lower lobe of
right lung was available for ventilation until the chest
could be opened to lift the tumour off the airway. To
this end, we used a noncompressible armoured tube.
We anticipated that the upper and middle lobes could
be opened up with positive pressure ventilation, and
indeed this was the case. This plan was for the worst
possible scenario in which both bronchi and the
carinal area of the trachea could be compressed by
the tumour.
Other recommended alternatives are cardio-
pulmonary bypass standby (9), ventilation through
a rigid bronchoscope or changing the position of
the patient to take the weight of the tumour off
the airway. We did not have the facility for
cardiopulmonary bypass, but we were ready for a
change in position at any time prior to exposure of
the mass and a rigid bronchoscope was kept ready for
emergency ventilation. We also took the precaution of
keeping the patient at a very light plane of anaesthesia
during the period of maximum risk, from the time
of induction to the time when the tumour became
accessible in the surgical field, with the help of nerve
blocks for intubation, epidural anaesthesia for
surgery and assured one lung ventilation.
We could have fashioned a hole above the tip of
the tube facing the left side to also ventilate the left
lung. However, if the tumour weight were to block
the carina or the more distal left bronchus, a hole in
the tracheal portion of the tracheal tube would have
been an alternative exit for inspired gases to leak
back into the mouth in the face of a distal obstruction.
All these were possible in our patient in whom the
inspiratory pressures rose in spite of the chest being
open as soon as atracurium was given, indicating a
compression of airways.
The use of local blocks was of immense help in
that the patient could be intubated at a safe, light
plane of anaesthesia. The alternative of topical local
anaesthetic spray for the upper airway has been
patchy and not entirely satisfactory in our experience
(17). The ensuing struggle with dangerous pressure
changes in the thorax could lead to the very problems
we wished to avoid. Awake intubation could have
resulted in serious hypoxia in our patient who was
already breathless but quite vigorous. Thus, we opted
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 MANAGEMENT OF AN INFANT WITH ANTERIOR MEDIASTINAL MASS
for just enough anaesthesia to use the spray enabling
us to place the blocks. The intubating conditions
provided by the blocks in addition to the local spray
was entirely satisfactory.
Preoperative placement of an epidural catheter for
analgesia could minimize general anaesthesia during
critical intra- and postoperative periods. In our
clinical setting of nonavailability of potent analgesics,
regional blocks are the only reliable method of
analgesia (18). The compromise of its placement
during the critical period of one lung anaesthesia.
was justified by the patient’s stable condition in left
lateral position.
In conclusion, anaesthesia for mediastinal mass in
an infant requires intense involvement with airway
safety. Certain norms of routine anaesthetic practice
such as dual lung ventilation may be flouted as a
part of a calculated risk to ensure the safety in that
particular situation.
References
1 Halpern SH, Chatten J, Meadows AT et al. Anterior mediastinal
masses. Anesthesia hazards and other problems. J Pediatr 1983;
102: 407–410.
2 Bittar D. Case history number 84: respiratory obstruction,
associated with induction of general anesthesia in a patient
with mediastinal Hodgkin’s disease. Anesth Analg 1975; 54:
399–403.
3 John RE, Narang VPS. A boy with an anterior mediastinal
mass. Anaesthesia 1988; 43: 864–866.
 1999 Blackwell Science Ltd, Paediatric Anaesthesia, 9, 439–443
443
4 Todres LO Reppert SM, Walker PF et al. Management of
critical airway obstruction in a child with mediastinal tumour.
Anesthesiology 1976; 45: 100–102.
5 Keon TP. Death on induction of anesthesia for cervical node
biopsy. Anesthesiology 1981; 55: 471–472.
6 Bray RJ, Fernandes FJ. Mediastinal tumour causing airway
obstruction in anaesthetised children. Anaesthesia 1982; 37:
571–575.
7 Levin H, Burszstein S, Heifetz M. Cardiac arrest in a child with
an anterior mediastinal mass. Anesth Analg 1986; 64: 1129–1130.
8 Neuman GG, Weingarten AE, Abramowitz RM et al. The
anesthetic management of the patient with an anterior
mediastinal mass. Anesthesiology 1984; 60: 144–147.
9 Aziz Khan RG, Dudgeon DL, Buck JR et al. Life threatening
airway obstruction as a complication to the management of
mediastinal masses in children. J Pediatr Surg 1985; 20: 816–822.
10 Pulleritus J, Holzman R. Anaesthesia for patients with
mediastinal masses. Can J Anaesth 1989; 36: 681–688.
11 Mackie AM, Watson CB. Anaesthesia and mediastinal masses.
A case report and review of literature. Anaesthesia 1984; 39:
899–903.
12 DeSoto H. Direct laryngoscopy as an aid to relieve airway
obstruction in a patient with mediastinal mass. Anesthesiology
1987; 67: 116–117.
13 Ferrari. R, Bedford RF. General anesthesia prior to treatment
of anterior mediastinal masses in pediatric cancer patients.
Anesthesiology 1990; 72: 991–995.
14 Mullen B, Richardson JD. Primary anterior mediastinal tumours
in children and adults. Ann Thorac Surg 1986; 52: 338–345.
15 Fischer M, Alagesan R, Bedford RF et al. Anesthetic
management of mediastinal masses revisited. Anesthesiology
1990; 73: A1079.
16 Johnson L, Hurst DB, Mayers I. Cardiopulmonary effects of an
anterior mediastinal mass in dogs anesthetized with halothane.
Anesthesiology 1991; 74: 725–728,.
17 Vas L, Naregal P, Nobre S et al. Anaesthetic management of a
child with bronchopleural fistula for left pneumonectomy. Paed
Anaesth 1999; in press.
18 Vas L, Narega P, Sanzgiri S. Some vagaries of neonatal epidural
anaesthesia. Paed Anaesth 1999; 9: 217–223.
Accepted 22 February 1999