Life-threatening airway obstruction as a complication to the management of mediastinal masses in children

Life-threatening airway obstruction from large mediastinal masses in children poses a difficult diagnostic and therapeutic dilemma, requiring the close coordination of a pediatric surgeon, anesthesiologist, radiologist, and oncologist. To focus on this problem, the anesthetic and surgical management of 50 consecutive children with mediastinal masses treated between 1978 and 1984 were reviewed. Thirty children presented with respiratory symptoms; nine had life-threatening respiratory compromise with dyspnea, orthopnea, and stridor. Thirteen of these symptomatic children had marked compression of the trachea and/or mainstem bronchi on radiographic studies. The tracheal cross-sectional area which was measured by computed tomography was decreased by 35% to 93% of the normal tracheal dimensions in these children. Nonresectable malignant neoplasms including lymphoma, Hodgkin's disease, rhabdomyosarcoma, and neuroblastoma were the eventual diagnoses in 10 of these patients. The other 3 patients were less than 4 years old and had benign lesions. General anesthesia was judged to be prohibitively risky in 5 of 13 patients. The diagnosis was established by node or needle biopsy under local anesthesia, and general anesthesia was deferred until the compromised airway was alleviated by radiation and chemotherapy. General anesthesia with endotracheal intubation was administered to 8 patients, 5 of whom developed total airway obstruction. Using a variety of maneuvers, ventilation was reestablished in all 5 patients. This experience supports the following conclusions: (1) Children with mediastinal masses that are associated with severe tracheobronchial compression (greater than 1/3 decrease in luminal area) are at grave risk for total airway obstruction during general anesthesia; (2) Chest CT scan is a reliable method to evaluate the extent of tracheobronchial compression in children with mediastinal masses; (3) The chest CT is not only valuable in preoperative assessment, but also in post therapy evaluation of the pediatric airway; (4) Patients in whom an unresectable malignant neoplasm is suspected, histologic diagnosis can be safely secured by open or needle biopsy under local anesthesia; (5) If a histologic diagnosis cannot be established without general anesthesia, these critical patients should be treated with steroids, chemotherapy, and radiation to restore the child's airway; and (6) General anesthesia in these airway compromised patients should be reserved for selected patients in whom total resection is likely.