Case Report
Large Anterior Mediastinal Mass in a Pediatric Patient with an Unusual Presentation
Titilopemi Aina*
Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, USA
*Corresponding author: Aina, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital/Baylor College of Medicine, 6621 Fannin, A3300, Houston, TX 77030, USA
Published: 22 May, 2017
Cite this article as: Aina T. Large Anterior Mediastinal Mass in a Pediatric Patient with an Unusual Presentation. Ann Clin Case Rep. 2017; 2: 1359.
Abstract
Anterior Mediastinal Masses (AMM) can range in presentation from an asymptomatic incidental finding to significant cardiorespiratory compromise. Symptoms do not always correlate to the degree of compression. Patients with AMM are at high risk for hemodynamic instability and cardiovascular arrest with induction of anesthesia. This report describes a child with a large AMM, who presented without classic symptoms, but instead with a right orbital cutaneous lesion, requiring anesthesia intervention for diagnostic imaging of the eye. It is imperative, especially in these unexpected presentations, to have a high-index of suspicion.
Introduction
Anterior Mediastinal asses (AMM), because of their proximity to many vital structures, are associated with a high risk of perioperative morbidity and mortality. Symptoms frequently do not correlate to the degree of compression; therefore, asymptomatic patients are still at risk for hemodynamic instability and death with induction of anesthesia. We present a case of a child with a large AMM, who did not present with classic symptoms, but with a right orbital cutaneous lesion requiring anesthetic management for appropriate diagnostic imaging.
Case Presentation
A previously healthy 3-year-old boy presented to the emergency room with worsening right
upper eyelid swelling for 3 weeks (Figure 1). His parents reported associated cough, nasal congestion,
malaise, fever, and night sweats. While supine for an orbital Computed Tomography (CT), the
patient developed tachypnea with stridulous breathing. The anesthesiology service was asked to help
facilitate a “quick” orbital CT scan with general anesthesia. A chest radiograph was obtained in the
interim, and upon review, demonstrated a large anterior AMM, and small bilateral pleural effusions
(Figure 2). The CT request was then expanded to include the chest and abdomen. Due to this new discovery, it was deemed more appropriate to avoid a general anesthetic and instead proceed with
sedation for the CT study. On physical exam, the patient was found to have labored breathing,
and was lying in the left lateral decubitus position. His right eye was swollen and draining. He was
transferred to the CT imaging suite and placed in the left lateral decubitus position and spontaneous
ventilation was maintained. The surgical team was called to the bedside by the anesthesiology team.
Intravenous sedation was initiated and maintained with a dexmedetomidine infusion at 0.5 mcg/
kg/min, and intermittent ketamine boluses up to a total of 20 mg. The CT scan was completed in 6
minutes.
The patient tolerated the CT scan with adequate breathing, oxygen saturations, and blood
pressure throughout. The imaging revealed a 10 cm anterior mediastinal mass compressing the
brachiocephalic veins and trachea up to the carina. There was an associated large pericardial effusion
and small bilateral pleural effusions. He subsequently underwent a mediastinal biopsy under local
anesthesia and sedation, again with administration of ketamine and dexmedetomidine. The final
pathology results demonstrated an aggressive T-cell lymphoma, mandating initiation of therapy
with steroids and chemotherapy.
Figure 1
Figure 2
Figure 3
Figure 3
Texas Children’s Hospital – Anterior Mediastinal Mass and
Perioperative Care Algorithm (Authors: Rahul Baijal, MD, Lisa Caplan, MD).
Discussion
The mediastinum, bordered by the pleura, diaphragm and thoracic inlet, can be divided into
anterior, middle, and posterior compartments. Masses may develop in any of these 3 compartments.
The most common causes of anterior mediastinal masses are: thymoma, teratoma, thyroid lesion,
and lymphoma [1]. AMMs can pose serious risks to a patient under general anesthesia, such as: severe airway obstruction, vascular compression, and cardiac collapse.
Preoperatively, patients can present with a range of symptoms,
including but not limited to: cough, dyspnea, wheezing, orthopnea,
and Superior Vena Cava (SVC) syndrome. Those who present with
orthopnea, features of SVC syndrome, and bronchial compression,
are more likely to have anesthetic complications [2-4]. Pretreatment
of the mediastinal mass with steroids, empiric chemotherapy, and/
or radiotherapy may relieve the obstructive/compressive symptoms.
However, this remains controversial, due to concerns that it may
limit the accuracy of tissue diagnosis [5]. Our patient had a large
AMM that presented with a rare finding of eyelid swelling. This was
eventually diagnosed as cutaneous evidence of the lymphoma. No
respiratory or vascular compression signs were noted prior to arrival
in the emergency room. However, on presentation, he was noted to
have orthopnea, stridor, pleural effusion and pericardial effusions;
which are all classic symptoms of AMM.
For patients with a possible mediastinal mass, the first step is
to obtain a chest radiograph. Following the chest radiograph, a CT
can help to further delineate the features of the tumor. Additional
workup could include: echocardiogram and pulmonary function
tests [1,3,4]. Ultimately, tissue diagnosis will be necessary. There is no
ideal anesthetic technique for a patient with AMM, as any technique
can be associated with morbidity and mortality. However, the
overall anesthetic goals should include: maintenance of spontaneous
ventilation, coordination of appropriate equipment for airway and
cardiac support, and ensuring availability of emergency team members
[2]. Based on the presence or absence of respiratory symptoms, degree
of tracheal compression, mediastinal mass ratio and other factors,
patients may be classified as being at high or low risk (Figure 3). A
low risk patient, who does not have any respiratory symptoms or
tracheal compression by CT, may proceed with a general anesthetic.
However, the management of a high risk patient should include preprocedure
otolaryngology and cardiovascular surgery consults, as
well as availability of a rigid bronchoscope, extracorporeal membrane
oxygenator and/or cardiopulmonary bypass machine; in the event that respiratory or cardiovascular collapse occurs/develops during
sedation or anesthesia. In addition, the anesthetic management
should entail placing the patient in a position of baseline comfort
(likely lateral or prone), maintaining spontaneous ventilation, using
ketamine and dexmedetomidine [6], and avoiding muscle relaxants
or positive pressure ventilation. As this case demonstrates, it is
imperative to have a high-index of suspicion for an AMM during the
pre-operative evaluation of a child with a cutaneous eye lesion with
associated respiratory symptoms. Questions in the history should
therefore be targeted towards this possible diagnosis and further
workup obtained as deemed necessary [7].
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- Baijal R, Caplan L, Jackson A, Macias C. Evidence-Based Practice Summary - Perioperative Management of Anterior Mediastinal Masses. Texas Children’s Hospital Evidence-Based Outcomes Center. 2015.