Congenital cystic hygroma is a lymphatic lesion that can affect any anatomic subsite on the human body. But in most of cases, the head and neck region are prone to cystic hygroma. Within the neck the posterior triangle tends to be most frequently affected, but there is no significant demographic data.
Lymphangioma are thought to arise from the failure of lymphatics to connect the venous system. Whereas capillary and cavernous forms of lymphangiomas tend to form in the muscle. This leads to potentially life threatening airway compromise that manifests into noisy breathing.
Name : B/O Gowramma, Age : 5 days, Sex : male
The case was informed by the grandmother of the baby educated until the 3 rd standard in school. The family is from a low income group and the economic status is low. The complaint received was the presence of a swelling in the neck region of the baby that extended to the face.
A swelling in the neck extending to the face was noticed by USG scan done at term gestation. Delivery was conducted by Caesarean section and baby cried immediately after birth. The baby was fed with formulated milk & by the next day it was brought to VIMS –OPD.
No H/O fever, cough, cold
No H/O difficulty in swallowing
No H/O suggestive of respiratory difficulty
No H/O suggestive of cyanotic spells
No H/O vomiting, convulsion & jaundice
No H/O bowel/bladder disturbance
The case subject is the second child of the couple. The mother received regular ANC check-ups and IFA tablets were consumed as per prescription. There were no history about any other drug intake by the mother or infections and hospital admissions during the gestation period.
An USG scan done at the 5th month showed normalcy in growth. But the scan at the 9th month detected a swelling on the neck. The 1st child of the couple FT ND, still born (Anomalous baby). H/O in the family reported no H/O DM/HTN/ epilepsy /asthma in family members.
Appetite: Normal, Sleep: Normal, Bowel/bladder: Regular, Diet chart: Lactogen 1, 30 ml per feeding and 10 feeds per day, Treatment H/O: Not significant, Immunisation H/O: Not immunised.
Baby was comfortable & sleeping on grand mother’s lap. No pallor /icterus/ cyanosis/ clubbing / lymphadenopathy/ kilonyachia. Heart rate: 162 bpm. Respiratory rate: 45 breaths per min. Abdominal thoracic in pattern. Temperature - afebrile.
Height- 47 cms, Weight- 3 kgs, Head circumference: 33cms, Fontanelle- ant – 3*4 cms, post – 1* 2 cms, Oral cavity: large notched tongue, Spine: Normal, Neck movements: Normal
Large swelling present in left side of neck & face, extending from under surface of opposite side mandible to lower eyelid of same side. Measuring 10 cms in length, 15 cms breadth. Patchy bluish discoloration on the surface. No dilated veins / scar / pulsations. Soft cystic consistency, no bruit heard.
Cardio vascular system: S1, S2 heard, no murmurs.
Respiratory system: NVBS heard, no added sounds.
Per abdomen: Soft, no organomegaly.
Hb% — 14 gm%, TC — 7200 cells/ mm3, DC — N — 67, L34, E0, RBS — 45mg/dl, Bl.urea — 7mg/dl, Serum creatinine — 0.7mg/dl, Blood group — B+ ve, HIV/Hbsag — negative, FNAC — presence of serous fluid.
After proper pre- anaesthetic preparation-
Baby was connected with pre induction monitors — pulseoximeter, ECG
Pre medicated with inj Atropine — 0 15 mg iv
Preoxygention — for 3 mins. Baby was intubated with 3mm size uncuffed ET tube under inhalational induction with N2O+O2+ sevoflurane0-5% under adequate anaesthetic depth. IPPV done with JR Circuit.
Maintainence: N2O +O2 — (2+2 lts, intermintent sevoflurane — 0 5- 1% Analgesia- inj fentanyl 3µgi.v
Inj. atracurium - 1 mg bolus + 0.25 mg +0.25+ 0.25 +0.25 mg iv. Vitals monitored.
Recovery — reversal done by — inj atropine 0 15mg + inj Neostigmine 0 15 mg iv
Recovery was smooth and the baby was extubated on table. Vitals monitored & stable. Complications-nil.
Baby was shifted to surgical ICU with supplementation of oxygen by face mask, with adequate analgesia by inj. Diclofenac infusion and proper fluid management were carried out.
Heart rate: 160 bpm respiratory rate: 35 breaths per min, Temp: afebrile, CVS: S1, S2 heard, no murmurs, Respiratory system: NVBS heard. No added sounds.
Cystic Hygromas are abnormal growths that usually appear on a baby neck or head. They consist of one or more cysts. These are fluid sacs of lymphatics. Pre-operative management of these cases is an anaesthetic challenge.
Cystic hygroma involving airway is of utmost critical and case management was done by general anaesthesia and lateral intubation with ippv. Securing airway both preoperatively, intraoperatively and post operatively is the major criteria.
1) Miller's textbook of Anaesthesiology 7th edition
2) Wylie and Churchill textbook 5th and 7th edition
3) Smith's paediatric anaesthesiology
4) Stoelting textbook of coexisting diseases.
5) Barash textbook of Anaesthesiology.