Peri-operative anaesthesia challenges in large anterior mediastinal mass - A case report

Thymic mass is a rare tumor in the anterior mediastinum. They are usually of unknown etiology. About 50% of patients are diagnosed incidentally on chest radiographs. A 45 years, BMI-28, male patient presented to cardiac outpatient department with breathlessness and persistent cough for past three months. He also complained of generalized fatigue and nonspecific chest pain. On chest x-ray (PA view), there were diffuse opacities in middle and lower zone and no tracheal compression or deviation. Lateral neck X-ray also ruled out any airway compression. Computed tomography thorax revealed a huge mass occupying the prevascular compartment of mediastinum and insinuating the visceral compartment bilaterally with extension upto bilateral cardiophrenic and anterior costophrenic angles. CT-guided biopsy was consistent with thymolipoma which was surgically resected.Thymolipomas usually present with nonspecific symptoms. They pose a huge anaesthetic challenge during the peri-operative period in terms of difficult intubation, co-existing airway compression requiring reinforced tubes and fiberoptic guidance, the possibility of sudden airway collapse post-induction, risk of hypoxemia secondary to reduced functional residual capacity (FRC) and haemodynamic disturbances during and after removal of huge mass.

Relieving bronchial compression due to cardiomegaly: The role of aortopexy when left ventricular assist device support just is not enough

Enlarged cardiac structures, especially those on left side have the potential to cause airway compression in pediatric patients with chronic heart failure, owing to their proximity to and impact on the trachea-bronchial tree. Ventricular assist devices are effective in decompressing such hearts thereby alleviating airway problems. Aortopexy serves as an effective airway decompressive measure in cases with persistent airway compression despite effective cardiac decompression by ventricular assist devices. We report a case of 1-year-old male patient with dilated cardiomyopathy in whom airway compression persisted despite ventricular assist device implantation. Aortopexy was effective in relieving airway compression allowing for subsequent extubation and successful heart transplantation.

Cardiac evaluation of a child with stridor

This is the case of a 6-month-old boy who is diagnosed with, and treated for, a vascular ring, following several admissions to paediatric intensive care with difficult respiratory symptoms and ongoing failure to thrive. This case highlights the diagnostic challenge presented by these patients. Cardiovascular causes of paediatric airway compression are often under-recognized, with consequent delay in diagnosis. Although they are much less common than other causes of stridor, such as laryngomalacia or other tracheo-bronchial anomalies, chronic airway compression in childhood from vascular malformations carries significant morbidity and mortality. It is readily treatable and should not be overlooked. A high index of suspicion for mechanical compression should be maintained in small children with recurrent obstructive respiratory signs and symptoms or the older child presenting with dysphagia. The most prevalent vascular anomalies resulting in airway compression are a double aortic arch, right aortic arch with an aberrant left subclavian artery, innominate artery compression, left aortic arch with an aberrant right subclavian artery (rarely), and pulmonary artery sling. Rarely, complex congenital heart disease, itself leading to dilatation of the cardiac structures, may precipitate airway compromise, as in tetralogy of Fallot with an absent pulmonary valve syndrome or conditions with significant atrioventricular valve regurgitation causing left atrial enlargement. A dilated ascending aorta may compress the trachea, producing similar symptoms likewise with a cervical aortic arch with an aberrant sublclavian artery and ipsilateral ligamentum arteriosus. Such cases require a comprehensive diagnostic workup. Investigations include plain chest X-ray, echocardiogram, direct microlaryngoscopy and bronchoscopy, and CT angiography or cardiac MRI. A normal laryngoscopic examination should warrant further investigation in the presence of ongoing symptoms. An appreciation of aortic arch embryology is important in interpreting echocardiography and cross-sectional imaging in relation to the role of airway compression. Management often necessitates multidisciplinary collaboration among specialties, including ear, nose, and throat (ENT) specialists, paediatric cardiologists, respiratory physicians, intensivists, and cardiothoracic surgeons. Definitive treatment depends on the underlying pathology but usually involves surgical decompression or aortopexy. A proportion of patients will continue to exhibit symptoms following surgical release, due to ongoing weakness of the airway, and in severe cases may require ongoing respiratory support.

Aortopexy – an effective strategy for relief of left main bronchus compression

Congenital anomalies of aortic arch and pulmonary arteries can cause airway compression in children. We present a rare case of left main bronchus compression between the right pulmonary artery and descending thoracic aorta, which was successfully treated by aortopexy.