Letters to Editor
Huge macrostomia can lead to a difficult mask fit resulting in difficult inhalational induction and mask ventilation as the lateral extension of cleft would not be enclosed within the appropriate size face mask.[4,6] We preferred inhalational induction over intravenous in view of expected difficult airway and venous access. We opted for a bigger mask just to cover the clefts allowing insufflation with sevoflurane until the child became unresponsive. Gamgee pad with an oval opening corresponding to oral aperture helped ineffective mask ventilation using size 2 RBS mask. Wetting of the margin of the aperture helped in achieving a complete seal. Evidence from closed claim studies suggests that the commonest cause of airway related morbidity in paediatric patients is due to the inability to ventilate.[7] Safe, effective airway management requires a systematic individualised approach with clear strategies. Preoperative evaluation, anticipation of difficulty, preparation, planning for alternatives, judicious use of airway aids and management of complications constitute the key to success in difficult paediatric airway management.[8] Adequate planning and preparation helped us in achieving airway control and avoiding a major airway catastrophe. In the literature, various techniques including LMA, fibreoptic intubation and use of micropore adhesive[6] have been described to manage the airway. Gamgee pad is easily available, cheap, soft, atraumatic and acceptable. It can be easily reapplied any time in emergency situations. The surgical procedure necessitates introduction of a nasotracheal tube. It gives way for more critical assessment of new points of commissure and avoids reconstruction of orbicularis oris under tension. This repair is significant to achieve normal sphincter like function necessary for articulation and mastication.[1] To summarize, difficult paediatric airway is every anaesthesiologist’s nightmare. Airway management technique depends on the availability of suitable equipment, experience and expertise of the attending anaesthesiologist. We devised a simple solution to overcome the problem of difficult mask ventilation by using a Gamgee pad with an oval aperture corresponding to the normal mouth aperture.
Bindu George, Jui Lagoo, SM Narendra1, Jaes George Departments of Anaesthesiology and 1Plastic and Reconstructive Surgery, St. John’s Medical College Hospital, Bengaluru, Karnataka, India 490
Address for correspondence: Dr. Jui Lagoo, Elita Promenade, B7‑1101, JP Nagar 7th Phase, Opp. RBI Water Tank, Bengaluru ‑ 560 078, Karnataka, India. E‑mail: [email protected]
REFERENCES 1. 2. 3. 4.
5. 6. 7.
8.
Ahmed SS, Bey A, Parveen S, Ghassemi A. Bilateral transverse facial cleft as an isolated and asyndromic deformity. Int J Clin Pediatr Dent 2010;3:101‑4. Millard DR. Bilateral and rare deformities - Lateral facial cleft. Cleft Craft: The Evolution of its Surgery. 1st ed., Vol. 2. Boston: Little Brown; 1977. p. 769‑80. Khaleghnejad‑Tabari A, Salem K, Ghajar MF. Treatment of bilateral macrostomia (lateral lip cleft): Case report. Iran J Pediatr 2012;22:425‑7. Cladis FP, Lorler, Braunwald. Anesthesia for plastic surgery. In: Davis PJ, Cladis FP, Modoyoma P, editors. Smith’s Anesthesia for Infants and Children. 8th ed. Philadelphia: Mosby, Elsevier; 2011. p. 821‑41. Bhakta P, Ghosh BR, Roy M, Mukherjee G. Evaluation of intranasal midazolam for pre anaesthetic sedation in pediatric patients. Indian J Anaesth 2007;51:111. Jain S, Khan RM, Khan Y, Siddiqui SS, Nathani N. Anesthetic management of a pediatric patient with rare bilateral macrostomia. Paediatr Anaesth 2007;17:902‑4. Jimenez N, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB. An update on pediatric anesthesia liability: A closed claims analysis. Anesth Analg 2007; 104:147‑53. Cardwell M, Walker RW. Management of the difficult paediatric airway. Br J Anaesth CEPD Rev 2003;3:167‑70. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.139023
Application of Valsalva manoeuvre to facilitate resection of intradiploic arachnoid cyst Non‑traumatic intradiploic arachnoid cyst (IAC) is a rare benign skull lesion first described by Weinand et al.[1] It is presumed to be congenital in origin, and the natural history or prognosis of this condition is not well‑known owing to its rarity.[2] IAC contains cerebrospinal fluid, but it is not strictly confined to the diploic space as there is always a communication with the intracranial subarachnoid space.[3] Small, asymptomatic lesions do not require any active intervention and are followed‑up radiologically. Indian Journal of Anaesthesia | Vol. 58 | Issue 4 | Jul-Aug 2014
Letters to Editor
Surgery is indicated for progressive lesions causing local pain or localized swelling.[2,4] A 16‑year‑old female admitted with occipital headache was diagnosed with an occipital non‑traumatic IAC [Figure 1]. Resection of the cyst was carried out under general endotracheal anaesthesia in the prone position. During surgical resection, the periphery of the cyst was not easily accessible. Hence, brief Valsalva manoeuvre was applied to facilitate resection (delivery) of the lesion.[5] The Valsalva manoeuvre was applied intraoperatively three times for successful delivery of the cyst, and was well tolerated, without any adverse haemodynamic event. Surgical resection of the non‑traumatic IAC involves resection of the pedicle of the cyst and repair of dural defect. The Valsalva manoeuvre transiently increases intracranial pressure (ICP), and can be used to facilitate the trans‑sphenoidal resection of pituitary tumours and for confirmation of venous haemostasis. Valsalva manoeuvre can also facilitate resection of fourth ventricular neurocysticercosis.[5] In the present case, the manoeuvre helped extrusion of the IAC. The basis of the application of Valsalva manoeuvre to facilitate delivery of the cyst is that the increased ICP may be transmitted to the IAC through a communication between the IAC and the intracranial subarachnoid space, thereby making the lesion more conspicuous. However, one needs to be vigilant
about possible haemodynamic changes during the manoeuvre. Valsalva manoeuvre may lead to transient episodes of hypotension and tachycardia followed by hypertension and bradycardia. Application of the manoeuvre during posterior fossa surgery has been reported to cause ventricular arrhythmias.[6] Since non‑traumatic IAC is a very rare entity, no data specific to the anaesthetic management of this condition is available. To the best of our knowledge, this is the first report of successful application of Valsalva manoeuvre to facilitate resection of an IAC. Hence, we suggest that the Valsalva manoeuvre could facilitate surgical resection of otherwise inaccessible IACs.
Surya Kumar Dube, Girija Prasad Rath Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India Address for correspondence: Dr. Girija Prasad Rath, Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi ‑ 110 029, India. E‑mail: [email protected]
REFERENCES 1.
Weinand ME, Rengachary SS, McGregor DH, Watanabe I. Intradiploic arachnoid cysts. Report of two cases. J Neurosurg 1989;70:954‑8. 2. Hasegawa H, Bitoh S, Koshino K, Obashi J, Iwaisako K, Fukushima Y. Nontraumatic intradiploic arachnoidcysts–Reportoffivecases.NeurolMedChir(Tokyo)1992; 32:887‑90. 3. Yamaguchi S, Hirohata T, Sumida M, Arita K, Kurisu K. Intradiploic arachnoid cyst identified by diffusion‑weighted magnetic resonance imaging – Case report. Neurol Med Chir (Tokyo) 2002;42:137‑9. 4. Thomas TA, Rout D. Non‑traumatic intraosseous cerebrospinal fluid cyst with associated craniovertebral anomalies: A case report and suggested mechanism of formation. Neurol India 2010;58:122‑4. 5. Prabhakar H, Ali Z, Sharma MS. Valsalva’s maneuver to assist delivery of a neurocysticercosis cyst from the fourth ventricle. Anesth Analg 2008;107:731. 6. Dube SK, Panda PS, Kumar P, Kumar S, Goyal K. Ventricular arrhythmia during Valsalva maneuver applied to facilitate resection of fourth ventricular neurocysticercosis cyst. Saudi J Anaesth 2014;8:138‑9. Access this article online Quick response code Website: www.ijaweb.org
Figure 1: T2-weighted magnetic resonance imaging showing cyst lesion in the occipital region with herniation of the cerebellum into the cyst Indian Journal of Anaesthesia | Vol. 58 | Issue 4 | Jul-Aug 2014
DOI: 10.4103/0019-5049.139024
491
Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Huge macrostomia can lead to a difficult mask fit resulting in difficult inhalational induction and mask ventilation as the lateral extension of cleft would not be enclosed within the appropriate size face mask.[4,6] We preferred inhalational induction over intravenous in view of expected difficult airway and venous access. We opted for a bigger mask just to cover the clefts allowing insufflation with sevoflurane until the child became unresponsive. Gamgee pad with an oval opening corresponding to oral aperture helped ineffective mask ventilation using size 2 RBS mask. Wetting of the margin of the aperture helped in achieving a complete seal. Evidence from closed claim studies suggests that the commonest cause of airway related morbidity in paediatric patients is due to the inability to ventilate.[7] Safe, effective airway management requires a systematic individualised approach with clear strategies. Preoperative evaluation, anticipation of difficulty, preparation, planning for alternatives, judicious use of airway aids and management of complications constitute the key to success in difficult paediatric airway management.[8] Adequate planning and preparation helped us in achieving airway control and avoiding a major airway catastrophe. In the literature, various techniques including LMA, fibreoptic intubation and use of micropore adhesive[6] have been described to manage the airway. Gamgee pad is easily available, cheap, soft, atraumatic and acceptable. It can be easily reapplied any time in emergency situations. The surgical procedure necessitates introduction of a nasotracheal tube. It gives way for more critical assessment of new points of commissure and avoids reconstruction of orbicularis oris under tension. This repair is significant to achieve normal sphincter like function necessary for articulation and mastication.[1] To summarize, difficult paediatric airway is every anaesthesiologist’s nightmare. Airway management technique depends on the availability of suitable equipment, experience and expertise of the attending anaesthesiologist. We devised a simple solution to overcome the problem of difficult mask ventilation by using a Gamgee pad with an oval aperture corresponding to the normal mouth aperture.
Bindu George, Jui Lagoo, SM Narendra1, Jaes George Departments of Anaesthesiology and 1Plastic and Reconstructive Surgery, St. John’s Medical College Hospital, Bengaluru, Karnataka, India 490
Address for correspondence: Dr. Jui Lagoo, Elita Promenade, B7‑1101, JP Nagar 7th Phase, Opp. RBI Water Tank, Bengaluru ‑ 560 078, Karnataka, India. E‑mail: [email protected]
REFERENCES 1. 2. 3. 4.
5. 6. 7.
8.
Ahmed SS, Bey A, Parveen S, Ghassemi A. Bilateral transverse facial cleft as an isolated and asyndromic deformity. Int J Clin Pediatr Dent 2010;3:101‑4. Millard DR. Bilateral and rare deformities - Lateral facial cleft. Cleft Craft: The Evolution of its Surgery. 1st ed., Vol. 2. Boston: Little Brown; 1977. p. 769‑80. Khaleghnejad‑Tabari A, Salem K, Ghajar MF. Treatment of bilateral macrostomia (lateral lip cleft): Case report. Iran J Pediatr 2012;22:425‑7. Cladis FP, Lorler, Braunwald. Anesthesia for plastic surgery. In: Davis PJ, Cladis FP, Modoyoma P, editors. Smith’s Anesthesia for Infants and Children. 8th ed. Philadelphia: Mosby, Elsevier; 2011. p. 821‑41. Bhakta P, Ghosh BR, Roy M, Mukherjee G. Evaluation of intranasal midazolam for pre anaesthetic sedation in pediatric patients. Indian J Anaesth 2007;51:111. Jain S, Khan RM, Khan Y, Siddiqui SS, Nathani N. Anesthetic management of a pediatric patient with rare bilateral macrostomia. Paediatr Anaesth 2007;17:902‑4. Jimenez N, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB. An update on pediatric anesthesia liability: A closed claims analysis. Anesth Analg 2007; 104:147‑53. Cardwell M, Walker RW. Management of the difficult paediatric airway. Br J Anaesth CEPD Rev 2003;3:167‑70. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.139023
Application of Valsalva manoeuvre to facilitate resection of intradiploic arachnoid cyst Non‑traumatic intradiploic arachnoid cyst (IAC) is a rare benign skull lesion first described by Weinand et al.[1] It is presumed to be congenital in origin, and the natural history or prognosis of this condition is not well‑known owing to its rarity.[2] IAC contains cerebrospinal fluid, but it is not strictly confined to the diploic space as there is always a communication with the intracranial subarachnoid space.[3] Small, asymptomatic lesions do not require any active intervention and are followed‑up radiologically. Indian Journal of Anaesthesia | Vol. 58 | Issue 4 | Jul-Aug 2014
Letters to Editor
Surgery is indicated for progressive lesions causing local pain or localized swelling.[2,4] A 16‑year‑old female admitted with occipital headache was diagnosed with an occipital non‑traumatic IAC [Figure 1]. Resection of the cyst was carried out under general endotracheal anaesthesia in the prone position. During surgical resection, the periphery of the cyst was not easily accessible. Hence, brief Valsalva manoeuvre was applied to facilitate resection (delivery) of the lesion.[5] The Valsalva manoeuvre was applied intraoperatively three times for successful delivery of the cyst, and was well tolerated, without any adverse haemodynamic event. Surgical resection of the non‑traumatic IAC involves resection of the pedicle of the cyst and repair of dural defect. The Valsalva manoeuvre transiently increases intracranial pressure (ICP), and can be used to facilitate the trans‑sphenoidal resection of pituitary tumours and for confirmation of venous haemostasis. Valsalva manoeuvre can also facilitate resection of fourth ventricular neurocysticercosis.[5] In the present case, the manoeuvre helped extrusion of the IAC. The basis of the application of Valsalva manoeuvre to facilitate delivery of the cyst is that the increased ICP may be transmitted to the IAC through a communication between the IAC and the intracranial subarachnoid space, thereby making the lesion more conspicuous. However, one needs to be vigilant
about possible haemodynamic changes during the manoeuvre. Valsalva manoeuvre may lead to transient episodes of hypotension and tachycardia followed by hypertension and bradycardia. Application of the manoeuvre during posterior fossa surgery has been reported to cause ventricular arrhythmias.[6] Since non‑traumatic IAC is a very rare entity, no data specific to the anaesthetic management of this condition is available. To the best of our knowledge, this is the first report of successful application of Valsalva manoeuvre to facilitate resection of an IAC. Hence, we suggest that the Valsalva manoeuvre could facilitate surgical resection of otherwise inaccessible IACs.
Surya Kumar Dube, Girija Prasad Rath Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India Address for correspondence: Dr. Girija Prasad Rath, Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi ‑ 110 029, India. E‑mail: [email protected]
REFERENCES 1.
Weinand ME, Rengachary SS, McGregor DH, Watanabe I. Intradiploic arachnoid cysts. Report of two cases. J Neurosurg 1989;70:954‑8. 2. Hasegawa H, Bitoh S, Koshino K, Obashi J, Iwaisako K, Fukushima Y. Nontraumatic intradiploic arachnoidcysts–Reportoffivecases.NeurolMedChir(Tokyo)1992; 32:887‑90. 3. Yamaguchi S, Hirohata T, Sumida M, Arita K, Kurisu K. Intradiploic arachnoid cyst identified by diffusion‑weighted magnetic resonance imaging – Case report. Neurol Med Chir (Tokyo) 2002;42:137‑9. 4. Thomas TA, Rout D. Non‑traumatic intraosseous cerebrospinal fluid cyst with associated craniovertebral anomalies: A case report and suggested mechanism of formation. Neurol India 2010;58:122‑4. 5. Prabhakar H, Ali Z, Sharma MS. Valsalva’s maneuver to assist delivery of a neurocysticercosis cyst from the fourth ventricle. Anesth Analg 2008;107:731. 6. Dube SK, Panda PS, Kumar P, Kumar S, Goyal K. Ventricular arrhythmia during Valsalva maneuver applied to facilitate resection of fourth ventricular neurocysticercosis cyst. Saudi J Anaesth 2014;8:138‑9. Access this article online Quick response code Website: www.ijaweb.org
Figure 1: T2-weighted magnetic resonance imaging showing cyst lesion in the occipital region with herniation of the cerebellum into the cyst Indian Journal of Anaesthesia | Vol. 58 | Issue 4 | Jul-Aug 2014
DOI: 10.4103/0019-5049.139024
491
Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
