Anesthetic management of a neonate with congenital laryngeal cyst

Corresponding author: Ji Young Lee, M.D., Department of Anesthesiology and Pain Medicine, Yeouido St. Mary Hospital, The Catholic University of Korea College of Medicine, 62, Yeouido-dong, Yeongdeungpo-gu, Seoul 150-713, Korea. Tel: 82-2-3779-1944, Fax: 82-2-783-0368, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC Congenital laryngeal cysts are rare, with an incidence of 1.82 per 100,000 live births [1]. They arise from the glottic area (58.2%), ventricular fold (18.3%), vallecula (10.5%), epiglottis (10.1%), and the aryepiglottic fold, as an order of frequency [2]. A congenital laryngeal cyst may easily obstruct the smaller airway of a neonate [3]. During anesthesia for patients with laryngeal cysts, anesthesiolosists can face the risk of obscured views of the larynx, loss of the airway, risk of rupturing the cyst, and potential aspiration of cyst contents. A 3.83 kg-weighed, 21-day-old female neonate was scheduled for an elective operation on a laryngeal cyst. She was born at 39 weeks and two days of gestation by cesarean section at 3.7 kg body weight. She started to cough at 7 days after birth, exacerbated by feeding. Her chest x-ray was normal. The otolaryngologist heard stridor, and confirmed a laryngeal cyst by flexible fiberoptic laryngoscopy. They confirmed a 1.2 × 0.9 cm sized large fluid attenuation mass at the right oropharyngeal region immediately below the vallecula by CT (Fig. 1). Her weight gain was only 130 gm during the 3 weeks after birth. She was inactive and cried very weakly. The major concern in anesthesia was how to intubate the trachea of the neonate. Our flexible endoscope has an outer diameter of 3.1 mm, unusable through 3.0 mm and 3.5 mm inner diameter endotracheal tubes. We decided to attempt an awake intubation. When the neonate arrived at the operating suite, her blood pressure was 75/40 mmHg, heart rate was 135 beats/min, and SpO2 was 97%. We injected glycopyrrolate 0.04 mg intravenously. After sufficient preoxygenation at right-side down decubitus position, we attempted a direct laryngoscopy with a Macintosh #1 blade. However, while the attempted intubation failed, her SpO2 did not decrease. From a brief observation during the first attempt, the laryngeal cyst completely blocked our view of the larynx. It appeared that she did not need sedative or anesthetics for further intubation procedure because she was inactive and her struggling was very weak during laryngoscopy. After the second trial of laryngoscopy that brought the same result, we