Letters to Editor

LETTERS TO EDITOR – Anesthetic Management of clival chordoma with retropharyngeal extension: Importance of imaging

Neha Singh, MD*, Parnandi Bhaskar Rao, MD, PDCC**, Devendra Gupta, MD, PDCC***, Sushil Prakash Ambesh, MD****

*Assistant Professor, Department of Anaesthesiology & Critical Care, P.I.M.S, Pondicherry-605014, India

**Assistant Professor, Department of Anaesthesiology, Critical Care and Pain Medicine, AIIMS, Bhibaneshwar, Odisha, India

***Associate Professor, ****Professor

Department of Anaesthesiology,Intensive Care and Pain Medicine,SGPGIMS,  Lucknow- 226014, (U.P),  India

Correspondence: Dr. Neha Singh,MD; Assistant Professor,  Department of Anaesthesiology & Critical Care, P.I.M.S, Pondicherry-605014, (India); Phone: +91-04132656271; Mobile: 91-8056625735; Fax: 91-0413-2656272; E-mail: hinehabhu@rediffmail.com

Dear Editor,

Chordomas are rare but usually aggressive tumors originating from embryonic remnants of the primitive notochord which are usually extradural and induce bone destruction.1 Although 35%  occur in the skull base, they represent only 0.1% of all skull base tumors.2

We emphasize on the  importance of  as specialized imaging techniques for  planning definitive airway management which will lead to better perioperative outcome.

A 45 year old,148-cm,52 kg, ASA II  lady was presented  with history of  progressively increasing neck pain for 1 year, which aggravates on neck flexion and bilateral hard of hearing. Preoperative evaluation was satisfactory except for the involvement of XI and XII cranial nerves. As trans-oral approach was planned, we opted for an awake fiberoptic nasal intubation with tracheostomy backup in case of failed intubation. Patient was explained about the procedure and consent obtained. Pre-induction monitoring included electrocardiogram (ECG) lead II and V, noninvasive blood pressure (NIBP), heart rate (HR) and   peripheral oxygen saturation (SpO2).  Venous access was established by using two 16G cannula. She received intravenous midazolam (1.5 mg), fentanyl (100 µg) and propofol infusion @ 100-150 mcg/kg/min. During fibreoptic intubation it was impossible to pass the scope beyond the nasopharynx due to an obstruction, so  procedure was abandoned and surgical tracheostomy was performed under monitored anesthesia  care. Radiographic review showed that the lesion has filled the nasopharyngeal space, obstructing the passage of a flexible fibreoptic scope (Fig.1).  Following tracheostomy, anesthesia was induced with propofol (2.5 mg/kg), vecuronium bromide (0.1 mg/kg) and the circuit was connected to the tracheostomy tube. Anesthesia  was maintained with Air:O2 :: 50:50, isoflurane 1-2%, vecuronium infusion 1 mcg/kg/min infusion and fentanyl infusion 2 mcg/kg/hr. Surgery  was  performed  in prone  position   followed  by  supine  position and rest of the intraoperative   period  was  uneventful. The duration of surgery was 11 hrs.  Patient was shifted to neurosurgical ICU for elective  ventilation and decannulated on fourth postoperative  day.

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Figure 1 Ch0rd0na

Chordomas account for 1% of intracranial tumors and 4% of all primary bone tumors.2 Although survival from chordomas is generally considered to be poor,2   there has been improvement with modern treatments.3 Barrenechea IJ et al. mentioned the use of fibreoptic technique for  intubation in cases of  chordoma with cervical instability.4

As our plan of fibreoptic naso-tracheal intubation failed, tracheotomy was performed.  In cases of expected difficult airway, it is suggested to consider fibreoptic intubation approach as the initial method of choice as it helps in detailed viewing of the anatomy, making it easy to decide the further plan to secure airway in anticipated difficult airway. Preoperative review of the imaging also add to the predicting ability in such cases. Flexible fibreoptic laryngoscopy has been a major advance in the management of difficult intubation.5 Although elective fibreoptic intubation is mostly successful, there are few reports where this technique may fail or not be possible because of laryngeal pathologies or abnormalities.6

With this experience of failed flexible fibreoptic intubation later managed by doing tracheostomy, we propose assistance of specialized imaging techniques before taking a decision regarding definitive airway management.

REFERENCES

1.  Sundaresan N, Rosen G, Boriani S. Primary malignant tumors of the spine. Orthop Clin North Am. Jan 2009;40:21-36. [PubMed]

2.  Dahlin DC, Maccarty CS: Chordoma. Cancer 5  1952;28:1170–78.

3. Crockard HA, Steel T, Plowman N, Sıngh A, Crossman J, Revesz T et al. A multidisciplinary team approach to skull base chordomas. J Neurosurg 2001;95:175-83. [PubMed]

4. Barrenechea IJ, Perin NI, Triana A, Lesser J, Costantino P, Sen C. Surgical management of chordomas of the cervical spine. J Neurosurg Spine. 2007 ; 6:398-406. [PubMed]

5. Ovassapian A, Dykes MHN. The role of the fibre-optic endoscopy in airway management. Seminars in Anaesthesia. 1987;7:93–104. [Online Access]

6. Takenaka I, Aoyama K, Nakamura M, Fukuyama H, Urakami Y, Takenaka Y et al. Oral styletted intubation under video control in a patient with a large mobile glottic tumour and a difficult airway. Can J Anaesth 2002;49:203–6. [PubMed]

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