1

Introduction

Managing an anterior mediastinal mass (AMM) perioperatively presents significant challenges, particularly in paediatric patients undergoing diagnostic or therapeutic surgical interventions [ , ]. These masses reduce intrathoracic space and may cause fatal airway and cardiovascular compromise. They can compress the heart and great vessels, reducing venous return and causing arrhythmias, while also obstructing the trachea and main bronchi, impairing lung expansion.

Children often remain asymptomatic while awake due to preserved muscle tone, but symptoms become apparent during sleep, including dyspnoea, orthopnoea, developmental delay, feeding difficulties, and failure to thrive [ , ]. Under anaesthesia, loss of muscle tone predisposes them to airway collapse and vascular compression, which may result in a life-threatening crisis. Although anaesthetic strategies for paediatric AMM have been reported [ , ], this case is unique due to the challenges associated with the patient’s age, tumour size, and the planned video-assisted thoracoscopic surgery (VATS) procedure.

2

Case presentation

A one-year-old male infant, weighing 6 kg, presented with progressive respiratory distress for four months. Symptoms worsened in the supine position, affecting feeding and sleep, and were partially relieved in the left lateral decubitus position. A productive cough persisted for a month. Examination revealed decreased air entry on the left side.

Chest X-ray showed a large, round, opaque lesion on the left, shifting the mediastinum and trachea to the right ( Fig. 1 ). Contrast-enhanced CT (CECT) identified a 9.3 × 9.5 × 10.8 cm cystic teratoma in the anterior mediastinum, compressing the pericardium, pulmonary trunk, and left pulmonary artery while collapsing the left upper lobe and the apical segment of the left lower lobe. The patient was scheduled for VATS and mass excision. A multidisciplinary team including paediatric surgery, anaesthesia, cardiothoracic surgery, and paediatric cardiology was involved. The parents were counselled about the high-risk nature of the procedure.

Preoperative chest X-ray showing the left sided opaque mass causing tracheal deviation to right and mediastinal shift.

Anaesthetic Management.

A multi-tiered anaesthesia plan was developed.

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  Plan A: Standard intubation in the supine position using a 3.5 mm cuffed reinforced tube with a video laryngoscope, followed by one-lung ventilation via a flexible fiberoptic bronchoscope (FOB). Muscle relaxants would be administered only after confirming one-lung ventilation.

  
  
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  Plan B: If airway obstruction occurred, intubation would be attempted in the left lateral decubitus position with a conventional laryngoscope, followed by FOB-guided tube placement.

  
  
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  Plan C: If airway collapse occurred, a rigid bronchoscope was available, with the cardiothoracic team on standby for emergency intervention.

Preoperative arterial blood gas (ABG) was within normal limits. Nil per oral status was confirmed, and written informed consent was obtained. No sedatives were given preoperatively.

Intraoperatively, ASA standard monitors were applied, and the patient maintained 100 % oxygen saturation in the supine 20° head up position. Induction was performed using sevoflurane, midazolam (0.3 mg), fentanyl (5 mcg), and ketamine (10 mg), maintaining a minimum alveolar concentration of 0.7. Lidocaine 2 % was sprayed on the larynx to attenuate intubation responses.

The first intubation attempt with a 3.5 mm reinforced tube failed due to obstruction past the epiglottis, causing desaturation to 91 %. Bag-mask ventilation restored saturation to 100 %. A second attempt with a 4.0 mm uncuffed PVC tube was successful. A right femoral arterial line and right internal jugular venous catheter were placed for invasive monitoring. A 2.2 mm FOB (EndoView BR Series of Hugemed) confirmed tracheal placement before advancing the tube into the right main bronchus. A 5 Fr bronchial blocker (BB) was kept as a backup.

The patient was positioned slightly right lateral, and VATS commenced. Ventilation was pressure-controlled (15 cm H ₂ O) with a tidal volume of 35–40 mL, I:E ratio of 1:1.5, PEEP of 5 cm H ₂ O, and FiO ₂ of 50 %. Pneumomediastinum resulted in hypercapnia (EtCO ₂ 60–70 mmHg), necessitating increased respiratory rate and pressure control, maintaining permissive hypercapnia (EtCO ₂ 50–60 mmHg).

After mass excision, the endotracheal tube was repositioned at 10 cm in the trachea, confirming bilateral lung expansion. The procedure lasted 2 h. Postoperative ABG was normal, and the patient was extubated in the ICU after awakening. Recovery was uneventful, with a chest X-ray confirming lung expansion.

3

Discussion

AMM constitutes 35–55 % of mediastinal masses, with thymomas, teratomas, thyroid masses, and lymphomas being the most common in children [ ]. Lymphomas grow rapidly and infiltrate adjacent structures, leading to early symptoms. These tumours present with airway compression (cough, hoarseness, stridor, dyspnoea, orthopnoea) or cardiovascular compromise (tachycardia, syncope, superior vena cava syndrome, cyanosis) [ ].

Preoperative risk assessment includes CT/MRI, echocardiography, and dynamic airway imaging. If tracheal narrowing exceeds 50 %, airway obstruction is likely under anaesthesia [ ]. Supine imaging may be dangerous for children with critical airway compression [ ]. Flow-volume loops may predict perioperative airway collapse, but their additional benefit over CT remains uncertain [ ].

One-lung ventilation (OLV) techniques in children include.

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  Double-lumen tubes (DLT) (for age >8 years)

  
  
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  Single-lumen tube (SLT) advancement into a main bronchus

  
  
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  BB such as the 5 Fr Arndt blocker and Fuji Uniblocker, offering selective bronchial occlusion [ , ].

  
  
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  Fogarty vascular catheters lack a central lumen, requiring passive absorption atelectasis [ ].

VATS in infants is uncommon due to the rarity of AMM in this age group, large tumour-to-thorax ratio, and frequent malignancies. Pneumomediastinum can increase intrathoracic pressure, reducing venous return and cardiac output. Invasive hemodynamic monitoring is crucial [ ].

Maintaining spontaneous respiration during induction prevents airway collapse. Even after intubation, loss of chest wall tone can exacerbate airway and vascular compression. Rigid bronchoscopy and emergency tracheostomy should always be available. Cardiopulmonary bypass (CPB) may be required for cardiovascular collapse, though timely initiation is crucial to prevent hypoxic injury [ ].

Preoperative chemotherapy may reduce tumour size, but it can complicate histopathology and airway management due to mucositis. Intraoperative fluid management should prevent airway edema and hemodynamic instability [ ].

4

Conclusion

This case highlights the challenges of AMM in an infant undergoing VATS. Multidisciplinary planning, preoperative assessment, and perioperative vigilance are key to successful outcomes. Anticipating airway collapse and hemodynamic instability is critical, necessitating advanced airway equipment, emergency strategies, and CPB preparedness. Early team communication and family discussions are essential in optimizing care.

CRediT authorship contribution statement

Amrita Rath: Supervision, Conceptualization. Babli Kumari: Writing – original draft. Reena: Writing – review & editing, Writing – original draft. Steffi Dua: Visualization, Resources. Prem Kumar T.: Visualization, Resources.

Ethics approval

Not applicable.

Consent for publication

Written and informed consent was obtained prior to writing this article from the parents of the child.

Availability of data and material

The data and relevant materials are available from the corresponding author on reasonable request.

Funding

There was no funding and financial support for this study.