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.