Unusual case of respiratory obstruction during induction of anaesthesia.

Tins a e r o ~ cosceaNs an unusual case of respiratory obstruction during induction of anaesthesia, caused by a ~mour of the laryngeal inlet. An 18-month-old child weighing 8.3 kg was admitted for elective removal of a hydroeoele and repair of an inguinal hernia. The child had a personal history of congenital depressed chest, ,con Recklinghansen's disease, vomiting and failure to gain weight. Apart from a matemal history of yon Recklinghausen's disease with neurofibromata there was nothing contributory in the family history. Stools were loose and respiration noisy. On systemic examination e',ff&au-lait spots were noted and there was peetus cavus with indrawing of the intercostal and subcostal spaces; otherwise no abnormality was noted. There was hydrocoeIe of the cord on the right side. Laboratory examinations: bicarbonate 16 mEq/L, chloride 102 mEqlL, potassium 5.1 mEq/L, sodium 142 mEq/L and Hgb. 12.3' gin/100 ml. Chest x-ray showed peetus excavatum. There were no other abnormalities of the soft tissues. The pa~Sent was booked for a right hydrocoelectomy but -this was postponed because of croup developed on the previous day. The next day he was examined for respiratory infection, as lie had croup early in the morn/ng. The chest was clear to auscultation. A chest x-ray done after the examination did not reveal any abnormality. He was pre-medi.'eated with morphine 0.5 mg and hyosine 0.05 mg one hour preoperatively, On arrival in the operating room the patient had obstructed brearl~ing without apparent cause. A Montreal infant set was used to put the patient to sleep. After two minutes he became cyanotic. After cutting off all the anaesthetics except for oxygen, the patient became pink, and as t_here was no apparent obstruction another at-tempt was made to induce anaesthesia. Again there was cyanosis with respiratory obstruction. At .this stage laryngoscopy was done. A mass was visualized posterior to the arytenoids but covering the posterior half of the laryngeal opening (Figure 1). At first it was diflqeult to identify the cords. An 18-gauge Portex tube was passed into the trachea and it was suggested Chat the surgeon perform a traeheostomy to provide a reliable airway. An emergency tracheostomy was done the same day. An x-ray of the neck showed a soft tissue nodule in the region of the vocal cords and a barium swallow was done to localize the tumour (Figures 2, 3). A week later the child was taken back to the operating room .to excise the turnout through the mouth. This was abandoned as it was difficult to excise through a suspension laryngoscope. At this time a biopsy was done and the pathology report indicated a polypoid mass covered by polarized laryngeal type squamous epithe1/urn. A plexiform neuroma was present in the stroma.