BACKGROUND

1. ▪ Most common cause: lymphoma

2. ▪ Suspect in pts presenting for cervical mass biopsy.

3. ▪ Other dxs: neuroblastoma, teratoma, germ cell tumor, bronchogenic cyst, foregut cyst, lymphangioma, mesenchymal tumor

4. ▪ Symptoms due to compression of anatomic structures

5. ▪ Symptoms worse when supine

6. ▪ Symptoms may be relieved by lateral or upright position.

7. ▪ Clinical: cough, hoarseness, dyspnea, wheezing, orthopnea, stridor, chest pain, syncope, SVC syndrome, tracheal deviation, retractions

8. ▪ Asymptomatic or nonspecific: fever, fatigue, weight loss

PREOPERATIVE ASSESSMENT

1. ▪ Preoperative radiation tx may interfere with accurate histologic dx & optimal tx regimens.

2. ▪ Physical exam: orthopnea, tracheal deviation, jugular venous distention, wheezing, retractions, unilateral decreased breath sounds

3. ▪ CXR: tracheal deviation, tracheal compression, abnormal cardiothymic silhouette

4. ▪ Echo: direct compression of cardiac chambers and/or great vessels, pericardial effusion

5. ▪ CT: assess severity & location of tracheal compression

6. ▪ Preop sedation: avoid or give in monitored setting

7. ▪ Antisialagogue (e.g., glycopyrrolate) useful

8. ▪ Obtain IV access prior to OR, ideally in lower extremity.

9. ▪ Correct preexisting dehydration or hypovolemia.

INTRAOPERATIVE MANAGEMENT

1. ▪ Potential catastrophic airway or cardiovascular collapse during induction of anesthesia

2. ▪ Monitors: std; A-line for great vessel or cardiac compression

3. ▪ All sized endotracheal tubes and rigid bronch immed avail in OR

4. ▪ For severe cases, ECMO or CPB stand-by

5. ▪ Liberal fluid administration if great vessel/cardiac compression

6. ▪ Position: semi-recumbent, sitting, or lateral

7. ▪ Local anesthesia without sedation is safest strategy, but not feasible for small children.

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