AJA Asian Journal of Anesthesiology

Advancing, Capability, Improving lives

Letter to the Editor
Volume 51, Issue 2, Pages 99-100
Debesh Bhoi 1 , Maya Dehran 1 , Srinivas Raghavan 1 , Dalim Kumar Baidya 1
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Outline



Dear Editor,

Arteriovenous malformations (AVMs) in the oral and maxillofacial region are rare but potentially life threatening.1 Limited space in the oral cavity, distorted anatomy, risk of bleeding at minimal trauma, and possibility of dynamic change in the size of AVM subsequent to sclerosant injection make anesthesia management challenging. Anesthesiologists can come across such cases for sclerotherapy, surgical excision, and radiological procedures such as magnetic resonance imaging (MRI) or digital subtraction angiography (DSA).

A 7-year-old girl weighing 22 kg, presenting with a large AVM of the lower part of the face involving the lips, oral cavity, and tongue was scheduled for sclerotherapy (Fig. 1). There was no history of dysphagia, dyspnea, or obstructive sleep apnea. The mass that nearly filled the entire oral cavity left only 1 cm of space between the mass and upper lip. Systemic examination and hematological and biochemical investigations were normal. The nostrils were patent. An X-ray of the neck showed a narrow retroglossal space. MRI revealed the involvement of the buccal, submandibular, sublingual, and right retromolar regions. Computed tomography (CT) angiography showed a high-flow AV malformation.

Fig. 1.
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Fig. 1. Large orofacial arterio-venous malformation in a 7 year old girl.

The child was premedicated with ranitidine and xylometazoline nasal drops. Anesthesia was induced with sevoflurane in 100% oxygen and was maintained with inhalational sevoflurane conveyed by nasopharyngeal airway for oral fiber optic bronchoscopy (FOB). However, no structure could be identified, and it resulted in mild bleeding from the contact surface. A successive attempt with nasal FOB yielded a similar blood-tinged view. Subsequently, the oxygen saturation decreased to 93–95% and assisted ventilation became difficult. A Size 2 Cobra Perilaryngeal Airway (CobraPLA) was inserted after proper lubrication and successfully positioned. Succinylcholine (40 mg) was injected and a 5.0-mm cuffed endotracheal tube could be easily inserted in place through the CobraPLA. Anesthesia was then maintained with sevoflurane and N2O in O2 and fentanyl (25 mcg). The procedure lasted for 15 minutes. The trachea was extubated when she was fully awake.

As the procedure was associated with frequently turning of the head, a risk of bleeding, and engorgement of the lesion after injection2 endotracheal intubation was deemed necessary. Retromolar intubation could be used3 but as the right retromolar space of the child was involved this technique was not considered. FOB-guided intubation is difficult to perform in an awake child, and it is the same even after inhalational anesthesia due to distorted anatomy or bleeding. Laryngeal mask airway (LMA) can be used in such AVMs as a primary airway device or as a rescue tool.2 Classic, flexible, or proseal LMAs have big cuffs, and attempts at insertion of any of these devices can cause more trauma. Moreover, they are not good conduit for intubation. Intubating LMA can easily cause trauma and bleeding because of its rigid metallic structure and large cuff size. CobraPLA was chosen as it has a narrow head and is a good conduit for intubation; its deflated cuff is small in size, allowing easy passage through the narrow oropharyngeal space,4 and the inflated cuff protects against aspiration.

Sedative premedication should be completely avoided in such patients. Ketamine premedication was associated with sudden enlargement of AVM with loss of airway control in a 3-year-old child.5 Sclerotherapy with sodium tetradecyl sulfate is safe and effective, but may be associated with complications such as bleeding, acute blistering, hemoglobinuria, deep ulceration, nerve injury, coagulation disturbances, and embolization.2

In conclusion, CobraPLA should be considered as an important airway device for primary use or as a rescue device in the management of large orofacial malformations with airway compromise.


References

1
W. Chen, J. Wang, J. Li, L. Xu
Comprehensive treatment of arteriovenous malformations in the oral and maxillofacial region
J Oral Maxillofac Surg, 63 (2005), pp. 1484-1488
2
Y.K. Batra, N.B. Panda, S. Rajeev
Airway rescue with laryngeal mask airway during sclerotherapy of a large arteriovenous malformation in the oral and maxillofacial region
Paediatr Anaesth, 16 (2006), pp. 894-895
3
A. Mittal, Y. Dwivedi, K. Joshi, A. Saxena, A. Gupta
Molar approach of intubation in a neonate with large intraoral swelling
Indian J Anaesth, 55 (2011), pp. 312-313
4
D.K. Baidya, P. Khanna, A. Kumar, D. Shende
Successful anaesthetic management of a child with blepharophimosis syndrome and atrial septal defect for reconstructive ocular surgery
J Anaesthesiol Clinical Pharmacol, 27 (2011), pp. 550-552
5
A.K. Baronia, C.K. Pandey, S. Kaushik
Diffuse oral facial cavernous hemangioma causing severe airway obstruction after intramuscular ketamine
Anaesthesiology, 79 (1993), pp. 1421-1424

References

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