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.