2 CASE REPORT
The patient was a 5-year-old boy with a height of 110 cm and a body weight of 18 kg. In July 2016, a mass was identified in the middle of the dorsum of the tongue, and the patient was referred to the Department of Oral Surgery of Nagoya City University Hospital by a family dentist. The patient would snore when laid on his back while sleeping. Detailed examination revealed a 35 × 25 × 25-mm mass lesion on the dorsum of the tongue (Figs. 1 and 2). Regarding medical history, although the patient was being followed up by a local pediatrician for congenital adrenal hyperplasia, the follow-up had been completed at the time of this operation. The patient had no allergies or any family history, and preoperative examination revealed no particular findings. Under general anesthesia, resection of the mass lesion located on the tongue was planned.
Regarding anesthesia management of the patient, there were following two concerns: 1) A difficult airway due to the large mass present on the tongue and
2) Risk of airway obstruction associated with a swollen tongue after surgery.
Before the patient was anesthetized, an intravenous route was secured on the left forearm to prepare for the difficult airway that was expected after the induction of anesthesia. Prior to the induction of anesthesia, oxygenation was performed with 100% oxygen for approximately 3 min. Anesthesia was induced with 6 L/min of oxygen and 6% sevoflurane. After the onset of anesthesia, mask ventilation temporarily became difficult due to the effects of the tongue mass and glossoptosis; however, mask ventilation was feasible after administering 15 mg of rocuronium and using an oral airway. A decrease in peripheral capillary oxygen saturation associated with temporary dyspnea was not observed. Subsequently, 30 μg of fentanyl was administered, and after the muscle relaxant showed its effect, nasotracheal intubation was performed using McGRATHTM MAC (Minneapolis, MN, USA). Because the tongue mass was mobile, the tongue could not be completely excluded; however, the view using the McGRATH was of a Cormack–Lehane Grade 2, and intubation was successfully performed in the first attempt. Anesthesia was maintained at 1 L/min of oxygen, 2 L/min of air, 2% sevoflurane, and 0.1–0.2 μg/kg/min of remifentanil. During the surgery, 2 mg of dexamethasone was administered to prevent postoperative swelling of the tongue, and 200 mg of acetaminophen was administered for postoperative analgesia. Intraoperative findings included no swelling of the tongue at the end of the surgery. Therefore, extubation was considered possible in the operating room. After completion of the surgery, 50 mg of sugammadex, a muscle relaxant antagonist, was administered and the patient was extubated after body movement, eye opening, and sufficient spontaneous respiration were confirmed. After extubation, there were no issues with the patient’s respiratory condition. The duration of surgery was 1 h 27 min, time spent under anesthesia was 2 h 13 min, and the amount of blood loss was 6 g.
In the postoperative intensive care unit (ICU), Dexmedetomidine (0.4μg/kg/hr) was used for sedation, and additional dexamethasone was administered to prevent tongue swelling. The patient was managed in the ICU until the next morning, but no swelling of the tongue was observed. The patient was then discharged from the ICU because the respiratory status and vital signs were stable.