L i f e - T h r e a t e n i n g Airway Obstruction as a Complication to the
M a n a g e m e n t of M e d i a s t i n a l M a s s e s in Children
By Richard G. Azizkhan, David L. Dudgeon, James R. Buck, Paul M. Colombani, Myron Yaster, David Nichols,
Curt Civin, Sandra S. Kramer, and J. Alex Hailer, Jr
Baltimore, M a r y l a n d
9 Life-threatening airway obstruction from large me-
diastinal masses in children poses a difficult diagnostic and
therapeutic dilemma, requiring the close coordination of a
pediatric surgeon, anesthesiologist, radiologist, and on-
cologist: To focus on this problem, the anesthetic and
surgical management of 50 consecutive children w i t h
mediastinal masses treated between 1978 and 1984 w e r e
reviewed. T h i r t y children presented w i t h respiratory
symptoms; nine had life-threatening respiratory compro-
mise w i t h dyspnea, orthopnea, and stridor, Thirteen of
these symptomatic children had marked compression of
the trachea a n d / o r mainstem bronchi on radiographic
studies. The tracheal cross-sectional area which was mea-
sured by computed tomography was decreased by 35% to
93% of the normal tracheal dimensions in these children.
Nonresectable malignant neoplasms including lymphoma,
Hodgkin's disease, rhabdomyosarcoma, and neuroblas-
toma w e r e the eventual diagnoses in 10 of these patients.
The other 3 patients were less than 4 years old and had
benign lesions. General anesthesia was judged to be pro-
hibitively risky in 5 of 13 patients. The diagnosis was
established by node or needle biopsy under local anes-
thesia, and general anesthesia was deferred until the
compromised airway was alleviated by radiation and
chemotherapy. General anesthesia w i t h endotracheal intu-
bation was administered to 8 patients, 5 of w h o m devel-
oped total airway obstruction. Using a variety of maneu-
vers, ventilation was reestablished in all 5 patients. This
experience supports the following conclusions: (1) Chil-
dren w i t h mediastinal masses that are associated with
severe tracheobronchial compression (greater than 1 / 3
decrease in luminal area) are at grave risk for total airway
obstruction during general anesthesia; (2) Chest CT scan is
a reliable method to evaluate the extent of tracheobron-
chial compression in children with mediastinal masses; (3)
The chest CT is not only valuable in preoperative assess-
ment, but also in post therapy evaluation of the pediatric
airway; (4) Patients in whom an unresectable malignant
neoplasm is suspected, histologic diagnosis can be safely
secured by open or needle biopsy under local anesthesia;
(5) If a histologic diagnosis cannot be established w i t h o u t
general anesthesia, these critical patients should be
treated w i t h steroids, chemotherapy, and radiation to
restore the child's airway; and (6) General anesthesia in
From the Departments o f Surgery, Anesthesia, Radiology, and
Pediatrics, Johns Hopkins Children's Center, Baltimore.
Presented before the 16th Annual Meeting o f the American
Pediatric Surgical Association, Kohala Coast, Hawaii, May 1-4,
1985.
Address reprint requests to J. Alex Hailer, Jr, MD, Division o f
Pediatric Surgery, Johns Hopkins Children's Center, 60l North
Broadway, Baltimore, MD 21205.
9 1985 by Grune & Stratton, Inc.
0022-3468/8512006~0048503.00/0
816
these airway compromised patients should be reserved for
selected patients in whom total resection is likely.
9 1985 b y Grune & S t r a t t o n , Inc.
INDEX WORDS: Mediastinal mass; tracheobronchial com-
pression; airway obstruction.
E D I A S T I N A L masses in children represent a
M heterogenous group of life-threatening congen-
ital, infectious, and neoplastic lesions which pose diffi-
cult diagnostic and therapeutic dilemmas. Many
authors have addressed the nature and frequency of
respiratory symptoms in children with mediastinal
masses) -8 However, the occurrence of life-threatening
airway obstruction or cardiovascular collapse during
general anesthesia in these patients has not been
emphasized. 9'1~Instances of fatal or near fatal airway
obstruction during general anesthesia in children with
tracheobronchial compression have been recorded only
in anecdotal case reports. 9'JI-14 Based on our recent
experience we wish to emphasize the hazards of gen-
eral anesthesia in children with mediastinal masses
who have evidence of tracheobronchial compression or
cardiovascular compromise. We have outlined our
current approach for the management of these
patients.
MATERIALS AND METHODS
We reviewed the diagnostic, anesthetic, and surgical management
of 50 consecutive children (1 day to 18 years of age) with mediastinal
masses treated at the Johns Hopkins Children's Center between
1978 and 1984. There were 28 males and 22 females in this series.
Comparable to other reports in the literature, 1~ 30% (15 patients)
had benign disease whereas 70% (35 children) had malignant lesions
(Table 1). Neurogenic tumors were the most common lesions in
children under age 2 years; they accounted for 8 of 12 patients.
Lymphatic and neurogenic neoplasms were equally represented in
the 2- to 10-year age group. In children older than 10 years of age,
lymphoma and Hodgkin's disease were most prevalent; they com-
prised 13 of 16 patients in this group.
DiagnosticRadiography
The diagnosis of a mediastinal mass was established by conven-
tional PA and lateral chest radiographs in all the patients. In I0
children, a barium swallow or high kilovoltage radiograph was
helpful in assessing involvement of the tracheobronchial tree. How-
ever, these studies only afforded a two-dimensional view of the
trachea and significant tracheobronchial compression was occassion-
ally missed using these techniques. To delineate the extent and
involvement of the mediastinal mass, computed tomography scans
(CT) proved most useful in 40 patients. Contiguous 0.8 to 1 cm
Journal of Pediatric Surgery, Vo120, No 6 (December), 1985: pp 816-822
A I R W A Y OBSTRUCTION A N D M E D I A S T I N A L MASSES 817

Table 1. Mediastinal Masses in Children Table 2. Mediastinal Masses in Children

Age Age Age Radiographic

Diagnosis 0 - 2 Years 2 - 1 0 Years 1 0 - 1 8 Years Evidence of
Respiratory Symptoms Tracheobronchial Compression
Nonneoplastic
Bronchogenic cyst 2 ( 1) 2 m None 20 0
Cystic h y g r o m a 1 (1) 1 M i n i m a l to m o d e r a t e 21 4
Caseating granuloma 1 ( 1) -- m Severe 9 9
T h y m i c hyperplasia -- 1 Total n u m b e r of patients 50 13
L y m p h o i d hyperplasia -- 2

Neoplastic
Neurogenic t u m o r s * 8 ( 1) 7 (1)
Lymphoma -- 3 (1)
H o d g k i n ' s disease -- 2 (1)
Rhabdomyosarcoma -- 1 (1)
Teratoma* -- 1
Germ cell t u m o r -- 1 (1)
Lipoblastoma* -- 1
( ) Patients w i t h radiographic evidence of tracheobronchial c o m p r e s -
sion.
* Benign neoplasms included.
image sections were obtained from above the thoracic inlet to below
both hemidiaphragms. Since 1982 we have been able to measure
accurately the cross-sectional area of the trachea using the C T scan
(Siemens Somatom DR3). Cross-sections of the proximal, mid, and
distal trachea (using identical windows in all patients) were ana-
lyzed to determine tracheal luminl area. Sections with maximal
narrowing were measured and the cross-sectional areas were calcu-
lated by a method modified from Griscom/5 The data were then
compared with CT derived data from normal children) s'~6 Echocar-
diography was utilized to assess myocardial contractility and tumor
involvement of the pericardium, heart, and great vessels in children
with suspected large anterior mediastinal neoplasms. 13
RESULTS
Thirty (60%) of the children in this series presented
with respiratory symptoms. Twenty-one patients had
mild to moderately severe respiratory findings which
included cough, dyspnea on exertion, atelectasis, and
pneumonia. Four of these 21 children had significant
extrinsic tracheobronchial compression identified by
chest CT scan. The other 9 children presented with
severe respiratory symptoms of dyspnea at rest,
orthopnea, stridor, and cyanosis. All had marked tra-
cheal, carinal, or bronchial compression seen on chest
CT scan or on high kilovoltage radiographs (Table 2).
Thirteen children were radiographically identified
with severe tracheobronchial compression; 10 had
malignant neoplasms, most of which were unresectable
(Table 1). Furthermore, two of these ten children had
echocardiographic evidence of impaired cardiac con-
tractility due to tumor encasement of the heart and
great vessels. The other 3 children with airway
obstruction were all less than 4 years old and had
benign lesions (Table 1). No radiographic evidence of
tracheobronchial compromise was identified in the 20
asymptomatic children. The tracheal cross-sectional
areas of 14 children who had mediastinal masses
2
associated with or without respiratory symptoms or
6 (3) airway compromise were compared (Fig 1).
7 (1) Severe airway narrowing was identified by CT scan
1 in 11 patients and by high kilovoltage radiographs in 2
children. Tracheal cross-sectional area measured by
CT scan was decreased 35% to 93% in 10 of these
children. In eight of these patients the tracheal luminal
area was diminished by at least 50%. The tracheal
cross-sectional areas were normal in the other 3
patients; however, all 3 had almost total or total
mainstem bronchus obstruction. In these children
severe mediastinal shift, from either severe atelectasis
or lobar emphysema from a ball-valve type of obstruc-
tion, contributed significantly to the airway compro-
mise.
Thirty-seven children who had no evidence of tra-
cheobronchial or cardiac compromise underwent gen-
eral anesthesia and surgery without complication.
Based on clinical grounds general anesthesia was
judged prohibitively risky in 5 of the 13 patients with
marked tracheobronchial compression. Histologic
diagnosis was successfully obtained by node or needle
biopsy under local anesthesia in 4 patients with sus-
pected lymphatic neoplasms. Respiratory symptoms
and tracheal compression were alleviated within a few
days after initiation of intensive chemotherapy and
radiation (Fig 2). The fifth child, a 4-month-old infant
with severe respiratory distress, was presumed to have
a thoracic neuroblastoma based on the posterior loca-
tion of the mass and the age of the child. Although
histologic confirmation was not available, he was
treated with a combination of chemotherapy and
radiation. The bone marrow aspirate was negative for
tumor; however, the presence of elevated VMA levels
in a 24-hour urine collection supported the presump-
tive diagnosis. Six months later the child underwent a
delayed primary resection of a thoracic neuroblasto-
ma. He remains alive without evidence of disease 2
years after resection.
General anesthesia was induced in 8 of the 13
children with severe tracheobronchial compression.
Despite endotracheal intubation, total or near total
airway obstruction developed in 5 of 8 patients during
induction or emergence from anesthesia. Two of these
5 patients had mild to moderate respiratory symptoms
818 AZIZKHAN ET AL

Z~ PROXIMALTRACHEA
i [] me VRMC.EA /
0 DISTAL TRACHIEA /
275
<
/
/ A
ILl 9 0 9
n- 225 / " 9

ss A
175 Is S 0
< E ss.# ['1 9
"' E
0
< 125
n- ,,,.,,""" n 0 ,,,.'""
k- Fig 1. Tracheal cross-sectional area in 14
children w i t h mediastinal masses. Area (mm 2)
75 O *-I ,,o'* is plotted against age (yr}. The dotted lines
9
9' ' ' ~ ~ 0 A ~ ...o -'" 9 --
~ 99 indicate the upper and l o w e r boundries of
_~ ..~ ..... 9 normal tracheal luminal areas in 30 children, TM
25 Cross-sections w e r e measured at 3 tracheal
| .... II levels: proximal (L~), mid (F-I). and distal (O).
I I I I I I I I I I I I I I I I I I Asymptomatic patients are plotted as open
symbols while children w i t h severe symptoms
1 3 5 7 9 11 13 15 17 or a i r w a y compromise during anesthesia are
AGE (YEARS) plotted as solid symbols,

preoperatively (Fig 3); but all 5 children had a greater available for children with marked tracheal or bron-
than 50% decrease in tracheal cross-sectional area chial compression.
measured by CT scans. When airway obstruction In three of the eight children who received general
occurred, ventilation was restored by passing the endo- anesthesia, the mass (a bronchogenic cyst, cystic
tracheal tube distal to the obstruction, by changing the hygroma, and neurogenic tumor) was amenable to
patient's position (lateral or prone), or by extubation complete excision. Normal ventilation was re-estab-
and mask spontaneous ventilation with positive end lished in these patients. One child, with obstruction of
expiratory pressure (PEEP; 10 to 15 cm H20). Our the right mainstem bronchus from a caseating granulo-
preferred anesthetic technique now consists of sponta- ma, had an uneventful general anesthetic. Two chil-
neous ventilation with halothane and 100% 02. Paraly- dren with lymphoma, who had total airway obstruction
sis with muscle relaxants is avoided if at all possible. during anesthesia, were extubated while deeply anes-
As our experience increased with these children, car- thetized and supported by mask ventilation and 10 to
diopulmonary bypass (femoral to femoral) was made 15 cm HzO PEEP, until spontaneous ventilation

A PROXIMALTRACHEA
" 0 " ~ TRMC~A /
0 ~sT,,c "rnAc.. /
275 /
/
- /
/
U.l 225 /
<[
ooo~
-I 175 .s S 9
<[
E
uJ
"I" vE
O 125
Fig 2. Pretherapy and posttherapy tra- <[
cheal cross-sectional areas in 5 children w i t h rr
mediastinal masses complicated by severe tra- I- s * " ...-,~~
9 ~ ~A ~ A.o,
~ ~
cheobronchial compression. The area (mm 2) is 75
plotted against age (yr}. The dotted lines indi- " r~ oo- 9 9
c a t e the normal range f o r tracheal luminal
area. TM Cross-sections w e r e measured at 3 25 .. ..... |
tracheal levels: proximal {Z~), mid (E]), and
distal (0). Pretreatment measurements are U I I I I U I I I I I I I U I I I I
plotted as solid symbols whereas, posttreat-
1 3 5 7 9 11 13 15 17
ment measurements are plotted as open sym-
bols. AGE ( Y E A R S )
AIRWAY OBSTRUCTION AND MEDIASTINAL MASSES 819

Fig 3. Seventeen-year-old male with Hodgkin's disease. This patient had llfe-threatening airway obstruction during general
anesthesia. (A) Marked distal tracheal compression by tumor seen on CT scan. A r r o w points to compressed trachea. Scale is equal to 5 cm.
(B) CT scan showing normal distal tracheal lumen 6 months posttherapy. A r r o w points to trachea. Scale is equal to 5 cm.

resumed. An 11-year-old boy with Hodgkin's disease
could only be extubated several hours postoperatively
when he was able to sustain adequate spontaneous
ventilation. This patient could not ventilate in the
supine position and was managed successfully in the
lateral and prone positions. The eighth child, a 4-
year-old boy presumed to have a resectable benign
mediastinal lesion actually had a nonresectable rhab-
domyosarcoma involving the mid and distal trachea.
This child required tracheal stenting and controlled
mechanical ventilation for 1 week postthoractomy
(Fig 4). His airway was so critical that minimal move-
ment of the endotracheal tube would cause complete
airway obstruction. He was treated with intensive
chemotherapy and radiation and is alive 1 year after
therapy.
Despite major airway compromise, all of these chil-
dren survived their anesthetic and surgical procedures.
After completion of intensive chemotherapy or radia-
tion, chest CT scans were performed to assess the
tumor response to therapy (Fig 2). Significant
improvement in tracheal luminal areas were docu-
mented in patients following therapy. Although there
have been no hospital mortalities in these 50 children,
three have subsequently died of their malignant neo-
plasms.
DISCUSSION
Children with mediastinal masses who present with
respiratory symptoms or tracheobronchial compres-
sion are at grave risk for total airway obstruction in the
perioperative period. General anesthesia in children
with mediastinal masses may exacerbate the effects of
extrinsic airway compression in several ways. During
general anesthesia, lung volume is reduced due to an
increase in abdominal muscle tone and a decrease in
inspiratory muscle tone, the result of which is the loss
of the tethering effect of expanded lungs on the
airwaysJ 7 Large airway compressability increases as a
result of bronchial smooth muscle relaxation under

Fig 4. Four-year-old boy with severe dyspnea at rest from a mediastinal rhabdomyosarcoma. (A) Chest CT scan shows 9 0 % distal
tracheal narrowing; (B) Chest CT scan shows normal proximal trachea; A r r o w s identify the trachea.
820
general anesthesia; a decrease in expiratory flow rate
results, exacerbating the effect of extrinsic compres-
sion. is Paralysis eliminates diaphragmatic movement
in the caudal direction that is seen during spontaneous
ventilationJ s The normal transpleural pressure gra-
dient that distends the airways during inspiration will
be diminished; therefore, the airway caliber will be
further reduced and the effect of extrinsic airway
compression becomes magnified. Cardiac output in
these patients also may be severely compromised by
tumor involvement of the pericardium and great ves-
sels making these patients vulnerable to catastrophic
cardiovascular collapse during general anesthesia. The
negative inotropic effect of general anesthetics (eg,
halothane) and the venous impedance associated with
diaphragmatic paralysis and positive pressure ventila-
tion can further diminish cardiac output) 3'17
Tracheobronchial compression occurs in up to 55%
of children with newly diagnosed mediastinal Hodg-
kin's diseaseJ 9 Piro et al reported a large series of
patients with Hodgkin's disease, where in there was a
10% incidence of life-threatening airway complica-
tions during general anesthesia) ~ A few of these
patients were asymptomatic, and plain chest radio-
graphs did not reveal evidence of airway compromise.
The radiographic appearance of the mediastinal mass
can be misleading as to the presence of airway narrow-
ing) 6 Furthermore, the severity of pulmonary symp-
tomatology is not a reliable indicator of the degree of
tracheobronchial compromise in children with medias-
tinal masses. 1~CT scans can identify the precise loca-
MEDIASTINAL MASS ON CXR
DYSPNEA, POSITION INTOLERANCE
TRACHEOBRONCHIAL COMPRESSION ON CT SCAN
SUPERIOR VENA C A V A SYNDROME
ES
I I
I UNRESECTABLE
NEOPLASM SUSPECTED
I
! l
BX NODE I NO BIOPSY
NEEDLE BX WITHOUT GEN.
LOCAL ANES. ANESTHESIA
l
RADIO -CHEMOTHERAPY
BASED ON ADEQUATE
PATIENT AGE AND
LOCATION OF LESION AIRWAY
Fig 5, Algorhythm for management of children with mediastinal masses.
AZIZKHAN ET AL
tion and extent of involvement of the mass. They also
can detect extrinsic airway compression that may not
be apparent on routine chest radiography, conven-
tional tomography, or even high kilovoltage airway
films. Accurate measurements of tracheal cross-
sectional area should be compared to standards for
normal tracheal luminal area and also be compared to
uninvolved normal regions of the patient's trachea.
Most of the patients who were severely symptomatic
had decreases in tracheal cross-sectional area of at
least 50%. Infants and small children may be more
susceptible to extrinsic airway obstruction because the
airways are more compressible; but more importantly
because small decreases in airway diameter produce
relatively larger decreases in tracheal luminal area as
well as increases in airway resistance. Our data sup-
port the concept that tracheal narrowing greater than
35% may produce severe respiratory symptoms or an
increased risk of airway obstruction during general
anesthesia. Computed tomography is a reliable method
for identifying children at grave risk for airway
obstruction during general anesthesia,
Other diagnostic tests have been reported to be
useful in identifying patients at risk from further
cardiopulmonary compromise during anesthesia. 13
Pulmonary function studies were not routinely per-
for~aed in our series, but in cooperative adolescents we
have found them informative. Neuman et al, in a series
of 3 patients, advocated pulmonary function tests as a
sensitive method of detecting airway obstruction even
in asymptomatic childrenJ 3 They reported that the
1
NO
LOCAL OR GENERAL
LOCALIZED NEOPLASM I ANESTHESIA FOR
CONGENITAL LESION BIOPSY OR RESECTION
1
1
GENERAL ANESTHESIA I
ARDIOPULMONARY BYPASS
VAILABLE
1. COMPLETE EXCISION OF MASS IF INDICATED
2. BIOPSY: a. SITTING POSITION
b. ABILITY TO CHANGE PATIENT POSITION
C. SPONTANEOUS VENTILATION
D, AVOIDENCE OF MUSCLE RELAXANTS
AIRWAY OBSTRUCTION AND MEDIASTINAL MASSES
inspiratory limb of the flow volume loop was helpful in
diagnosing extrathoracic airway obstruction; converse-
ly, they found that the expiratory limb was able to
reveal intrathoracic airway obstruction. In addition,
we have found that bronchoscopy adds little informa-
tion in these patients and may be extremely hazardous
in an already compromised patient. Routine diagnostic
bronchoscopy should not be performed in children with
mediastinal masses. Finally, echocardiography may be
helpful in assessing myocardial contractility and tumor
involvement of the heart and great vessels. Encasement
of the pericardium or great vessels by tumor may
produce superior vena cava obstruction or cardiac
tamponade. The fixed low cardiac output associated
with these conditions may be further diminished by the
myocardial depression of general anesthesia and the
supine position of the patients.13
Thus the management of children with mediastinal
masses requires the close collaboration of a pediatric
surgeon, anesthesiologist, radiologist, and oncologist.
A presumptive diagnosis may be offered on the basis of
REFERENCES
1. Bower R J, Kiesewetter WB: Mediastinal masses in infants and
children. Arch Surg 112:1003-1009, 1977
2. Elder JS, Touloukian R J: Surgical diagnosis of mediastinal
lymphoma of childhood. Arch Surg 114:54-58, 1979
3. Grosfeld JL, Weinberger M, Kilman 3W, et al: Primary
mediastinal neopasms in infants and children. Ann Thor Surg
12:179-190, 1971
4. Hailer JA, Jr, Mazer DO, Morgan WW, Jr: Diagnosis and
management of mediastinal masses in children. J Thor Surg 58:385-
392, 1969
5. Hailer JA, Jr, Shermeta DW, Donahoo JS, et al: Life threaten-
ing respiratory distress from mediastinal masses in infants. Ann
Thor Surg 19:364-370, 1975
6. King RM, Telander RL, Smithson WA, et al: Primary medias-
tinal tumors in children. J Ped Surg 17:512-520, 1982
7. Oldham HN, Jr: Mediastinal tumors and cysts. Ann Thor Surg
11:246-275, 1971
8. Pokorny W J, Sherman JO: Mediastinal masses in infants and
children. J Thor Cardiovasc Surg 68:869-875, 1974
9. Halpern S, Chatten J, Meadows AT, et al: Anterior mediasti-
nal masses: Anesthesia hazards and other problems. J Pediatr
102:407-410, 1983
10. Piro AH, Weiss DR, Hellman S: Mediastinal Hodgkin's
disease: A possible danger for intubation anesthesia. Int J Radiat
Oncol Biol Phys 1:415-419, 1976
Discussion
Robert Filler (Toronto): Many of us are concerned
with the potential respiratory complications that can
be induced by general anesthesia in children with large
mediastinal masses. This paper clearly outlines the
serious problems that can occur and be encountered
when general anesthesia is given to these patients. The
821
patient age and location of the mass, but there is often
understandable reluctance in initiating radiation or
chemotherapy without a histologic diagnosis. Figure 5
illustrates a management protocol for the child with a
mediastinal mass. If there is symptomatic or radio-
graphic evidence of severe airway compression or
cardiovascular compromise, general anesthesia should
be reserved for selected patients who are likely to
undergo curative resection. Patients with localized
neoplasm or congenital lesions belong in this group.
Femoral to femoral cardiopulmonary bypass should be
made available for these patients. For patients with
suspected unresectable neoplasms, histologic diagnosis
can be safely secured by node or needle biopsy under
local anesthesia. In a few severely compromised
patients, a histologic diagnosis cannot be established
without a general anesthetic and these children should
be treated with steroids, chemotherapy, and radiother-
apy as a life-saving measure. A delayed biopsy or
resection under general anesthesia may be feasible
once the airway is no longer compromised.
11. Bray R J, Fernandes FS: Mediastinal tumor causing airway
obstruction in anesthetized children. Anes 37:571-575, 1982
12. Keon TP: Death on induction of anesthesia for cervical node
biopsy. Anes 55:471-472, 1981
13. Neuman GG, Weingarter AE, Abramowitz RM, et al: The
anesthetic management of the patient with an anterior mediastinal
mass. Anesthesiol 60:144-147, 1984
14. Todres ID, Reppert SM, Walker PF, et al: Management of
critical airway obstruction in a child with a mediastinal tumor. Anes
45:100-102, 1976
15. Griscom NT: Computed tomographic determination of tra-
cheal dimensions in children and adolescents. Radiol 145:361-364,
1982
16. Kirks DR, Fram EK, Vock P, et al: Tracheal compression by
mediastinal masses in children: CT evaluation. A JR 141:647-651,
1983
17. Bergman NA: Reduction in resting end expiratory position of
the respiratory system with induction of anesthesia and neuromuscu-
lar paralysis. Anesth 57:14-17, 1982
18. Degraff AC, Bouhuys A: Mechanics of airflow in airway
obstruction. Ann Rev Med 24:111-134, 1973
19. Mandell GA, Lantieri R, Goodman CR: Tracheobronchial
compression in Hodgkin's lymphoma in children. A JR 139:1167-
1170, 1982
real question to all of us is which patients are at risk for
this complication; and I believe that the data in this
paper does, indeed, answer that; and our own experi-
ence would corroborate these findings. First, those
children who are clearly asymptomatic are really not
at risk, even despite the size of the mass; and 40% of
822
the patients in this series fell into that category, and
they had no problem, either by CT scan or clinically.
There is another group, with severe respiratory symp-
toms, which represents 205 of this whole series, who
clearly were at risk; and when CT scans were done in
that group, they showed marked narrowing of the
airway. There is the intermediate group, which repre-
sents approximately 40% of the patients, in whom one
is really not sure, with minimal symptoms or mild
symptoms, whether or not these patients really are
going to have a problem with general anesthesia; and
it's in this group that the measurement of the airway
cross-sectional diameter by CT scan, which was
described, seems to be most useful. In this day of
frequent CT scanning, I think probably that informa-
tion is available to all of us, and I think it is a very wise
maneuver to have that type of information available.
For those who, then, appear to be at greatest risk, the
question is, what does one do? We would agree with
the plan of biopsy under local anesthesia, if that is
feasible, but in certain selected cases that really isn't
possible. We also would go ahead with treatment prior
to establishing definitive tissue diagnosis in children
who clinically have malignant disease. In general, our
AZlZKHAN ET AL
pathologists have told us that with a few days of
treatment, especially those with lymphomas that are
treated with steroid therapy alone, that they can still
make a proper diagnosis several days later, when the
airway symptoms disappear and then tissue diagnosis
can be obtained.
Richard Azizkhan (closing): The question is, why
does general anesthesia make these patients more at
risk? Right now, we don't really understand why. It
may be related to the fact that lung volume is reduced
during general anesthesia and, also, inspiratory muscle
tone is decreased, the result of which is the loss of the
tethering effect of the expanded lung on the airways.
Furthermore, general anesthesia has been associated
with smooth muscle relaxation in the airways, which
may increase airway compressability; and, in addition,
diaphragmatic paralysis diminishes the normal trans-
pleural pressure gradient that distends the airway
during inspiration. All these effects combined exacer-
bate the effect of extrinsic airway compression. The
purpose of this paper is basically to point out that
airway complications during general anesthesia, in
these types of patients, are significant, and that all of
us need to be more aware of them.