Discussion
YSTs, also called endodermal sinus tumors, are characterized by diverse
clinical, pathologic, and prognostic features1. YSTs
generally exhibit poor prognosis, as they tend to recur locally, and a
high incidence of metastasis2. Therefore, therapy
includes extensive surgical resection, intensive combinations of
chemotherapy drugs, and occasional radiation therapy. However, patients
who are subjected to general anesthesia after facial radiotherapy are at
a significantly high risk of developing difficult airways. To the best
of our knowledge, no cases of anesthesia induction in patients with
facial YST have been reported. This report describes the anesthesia
process for spontaneous ventilation bronchoscope intubation in a
potentially difficult airway of a 7-year-old child with YST.
In the clinic, the prediction of a difficult airway requires
comprehensive evaluation; however, there are certain characteristics
that have been identified in patients requiring awake tracheal
intubation (AKI), such as those with head and neck pathology (including
malignancy, previous surgery, or radiotherapy), reduced mouth opening,
limited neck extension, and progressive airway3. AKI
involves placing a tracheal tube in an awake, spontaneously breathing
patient, usually with the help of flexible bronchoscopy or video
laryngoscopy4. This allows the airway to be secured
before induction of general anesthesia, avoiding the potential risks and
consequences when managing a difficult airway in an anesthetized
patient. Because the patient in our case had undergone facial
radiotherapy and systemic chemotherapy and had restricted mouth opening
and limited head receding, there was a high risk of difficult airway
intubation. Therefore, fiberoptic bronchoscopy was the technique of
choice. In this case, a senior experienced anesthetist used fiberoptic
flexible bronchoscopy for intubation while maintaining spontaneous
breathing of the patient.
Moreover, because the patient’s cooperation is essential for AKI, local
anesthesia of the airway not only improves the child’s acceptance of an
airway device, but also blocks the airway reflexes. Some studies have
shown that awake fiberoptic intubation can be used in conjunction with
either inhalational or intravenous induction in
children5. Esketamine 10 mg and dexmedetomidine 10 µg
were administered in our patient for analgesia and sedation during
anesthesia induction. Thus, their use during AKI can reduce patient
anxiety and discomfort and increase procedural tolerance.
Another concern regarding difficult pediatric airways is the limited
volume of topical local anesthesia that can be administered because of
the small stature of the patient and the scarcity of data on the safe
dosage of topical lidocaine. Our patient remained stable throughout the
perioperative period. Comparing the risks of inadequate airway
topicalization and of mild systemic lidocaine toxicity, combining
intravenous induction and airway topicalization modalities seems
favorable.
In conclusion, this is the first report of anesthesia in children with
primary maxillofacial YST. Combining intravenous induction and airway
topicalization modalities seems more favorable to the YST child with a
potentially difficult airway.