Airway Obstruction in Neonate by Velar Cyst Zhongping Cao, MD We describe a case of airway obstruction in a neonate by a velar cyst (a cyst located on the soft palate). We were unable to ventilate the infant’s lungs until the cyst was punctured with a syringe. (A&A Case Reports. 2015;5:17.)
A
velar cyst is an epithelial cyst located on the soft palate. Fortunately, these are rare. We observed such a cyst when attempting to ventilate a neonate’s lungs. Ventilation was not possible until we observed the cyst in the airway, punctured it with a needle, and aspirated the fluid with a syringe. Consent to publish this report was obtained from the mother.
CASE DESCRIPTION
A healthy pregnant woman aged 27 years, at 40 weeks' gestation, underwent cesarean delivery for fetal distress under unremarkable epidural anesthesia. Five minutes after the start of the procedure, a female baby was delivered. The initial Apgar score was 2 (her heart rate surpassed 100 beats/ min). We attempted endotracheal intubation because the baby was not breathing. However, our view of the glottis was obscured by a 2 cm × 2 cm cyst on the soft palate over the base of the tongue (Fig. 1). We were unable to ventilate the baby’s lungs by mask. The baby’s heart rate rapidly decreased to 60 beats/min. We administered 0.05 mg epinephrine through the umbilical vein and began chest compressions. The cyst was punctured with a 5-mL syringe. We aspirated about 4.5 mL of white thick liquid from the cyst. With the cyst deflated, the baby cried. We administered supplemental oxygen and intraoral suction. The baby rapidly recovered to an Apgar score of 10. On pathologic examination, the cyst liquid was composed of squamous epithelial cells.
DISCUSSION
The main measures in neonatal respiration resuscitation are suction, ventilation with oxygen via facemask and breathing bag, endotracheal intubation, and pulmonary expansion.1,2 Suction is critical to remove amniotic fluid, meconium, and blood. Endotracheal intubation should be used to provide additional suction and oxygen inspiration if necessary.1,2 The initial Apgar score of 2 in an infant without evidence of ventilation required immediate endotracheal intubation. The cyst was immediately identified as the problem, but we hesitated momentarily due to the unknown characteristics
Figure 1. There was no time to take a picture during the resuscitation of this infant. However, we attempted to reconstruct the appearance of the cyst in an infant model. The uvula, epiglottis, and glottis could not be seen when we tried to perform endotracheal intubation. The arrow represents the puncture site.
of the cyst, considering the alternative of cricothyroid membrane puncture.3 We chose needle puncture and aspiration, which proved to be immediately effective. Squamous epithelial cells cover the skin, as well as part of the mouth, throat, and nasopharynx. This cyst contained squamous epithelial cells, which is rarely seen in neonates. We have no information on how this formed. E REFERENCES 1. Obara S, O’Leary JD. Congenital tracheal stenosis: unanticipated and anticipated difficult airway management in a neonate. AA Case Rep 2014;3:120–2 2. Sunder RA, Haile DT, Farrell PT, Sharma A. Pediatric airway management: current practices and future directions. Paediatr Anaesth 2012;22:1008–15 3. Coté CJ, Hartnick CJ. Pediatric transtracheal and cricothyrotomy airway devices for emergency use: which are appropriate for infants and children? Paediatr Anaesth 2009;19 Suppl 1:66–76
From the Department of Anesthesia, the Affiliated Hospital of Armed Force Medical University, Tianjin, China. Accepted for publication January 8, 2015. Funding: This work was supported by the National Natural Science Founding of China (81270560). The author declares no conflicts of interest. Address correspondence to Zhongping Cao, MD, Department of Anesthesia, the Affiliated Hospital of Armed Force Medical University, Chenglin Road NO 222, Hedong district, Tianjin, 300162, China. Address e-mail to [email protected]. Copyright © 2015 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000160
July 15, 2015 • Volume 5 • Number 2
cases-anesthesia-analgesia.org
17
A
velar cyst is an epithelial cyst located on the soft palate. Fortunately, these are rare. We observed such a cyst when attempting to ventilate a neonate’s lungs. Ventilation was not possible until we observed the cyst in the airway, punctured it with a needle, and aspirated the fluid with a syringe. Consent to publish this report was obtained from the mother.
CASE DESCRIPTION
A healthy pregnant woman aged 27 years, at 40 weeks' gestation, underwent cesarean delivery for fetal distress under unremarkable epidural anesthesia. Five minutes after the start of the procedure, a female baby was delivered. The initial Apgar score was 2 (her heart rate surpassed 100 beats/ min). We attempted endotracheal intubation because the baby was not breathing. However, our view of the glottis was obscured by a 2 cm × 2 cm cyst on the soft palate over the base of the tongue (Fig. 1). We were unable to ventilate the baby’s lungs by mask. The baby’s heart rate rapidly decreased to 60 beats/min. We administered 0.05 mg epinephrine through the umbilical vein and began chest compressions. The cyst was punctured with a 5-mL syringe. We aspirated about 4.5 mL of white thick liquid from the cyst. With the cyst deflated, the baby cried. We administered supplemental oxygen and intraoral suction. The baby rapidly recovered to an Apgar score of 10. On pathologic examination, the cyst liquid was composed of squamous epithelial cells.
DISCUSSION
The main measures in neonatal respiration resuscitation are suction, ventilation with oxygen via facemask and breathing bag, endotracheal intubation, and pulmonary expansion.1,2 Suction is critical to remove amniotic fluid, meconium, and blood. Endotracheal intubation should be used to provide additional suction and oxygen inspiration if necessary.1,2 The initial Apgar score of 2 in an infant without evidence of ventilation required immediate endotracheal intubation. The cyst was immediately identified as the problem, but we hesitated momentarily due to the unknown characteristics
Figure 1. There was no time to take a picture during the resuscitation of this infant. However, we attempted to reconstruct the appearance of the cyst in an infant model. The uvula, epiglottis, and glottis could not be seen when we tried to perform endotracheal intubation. The arrow represents the puncture site.
of the cyst, considering the alternative of cricothyroid membrane puncture.3 We chose needle puncture and aspiration, which proved to be immediately effective. Squamous epithelial cells cover the skin, as well as part of the mouth, throat, and nasopharynx. This cyst contained squamous epithelial cells, which is rarely seen in neonates. We have no information on how this formed. E REFERENCES 1. Obara S, O’Leary JD. Congenital tracheal stenosis: unanticipated and anticipated difficult airway management in a neonate. AA Case Rep 2014;3:120–2 2. Sunder RA, Haile DT, Farrell PT, Sharma A. Pediatric airway management: current practices and future directions. Paediatr Anaesth 2012;22:1008–15 3. Coté CJ, Hartnick CJ. Pediatric transtracheal and cricothyrotomy airway devices for emergency use: which are appropriate for infants and children? Paediatr Anaesth 2009;19 Suppl 1:66–76
From the Department of Anesthesia, the Affiliated Hospital of Armed Force Medical University, Tianjin, China. Accepted for publication January 8, 2015. Funding: This work was supported by the National Natural Science Founding of China (81270560). The author declares no conflicts of interest. Address correspondence to Zhongping Cao, MD, Department of Anesthesia, the Affiliated Hospital of Armed Force Medical University, Chenglin Road NO 222, Hedong district, Tianjin, 300162, China. Address e-mail to [email protected]. Copyright © 2015 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000160
July 15, 2015 • Volume 5 • Number 2
cases-anesthesia-analgesia.org
17
