Users Online: 5136 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  
Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions | Subscribe | Contacts | Login 


RSACP wishes to inform that it shall be discontinuing the dispatch of print copy of JOACP to it's Life members. The print copy of JOACP will be posted only to those life members who send us a written confirmation for continuation of print copy.
Kindly email your affirmation for print copies to dranjugrewal@gmail.com preferably by 30th June 2019.

 

 
Table of Contents
CASE REPORT
Year : 2011  |  Volume : 27  |  Issue : 2  |  Page : 241-243

Anesthetic management of schwannoma of the base of the tongue


Department of Anaesthesia and Critical Care, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India

Date of Web Publication3-Jun-2011

Correspondence Address:
Upma B Batra
75, Triveni Apartments, Vikaspuri, New Delhi - 110018
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.81830

Rights and Permissions
   Abstract 

Schwannoma arising from the base of the tongue are very rare and only a few cases have been reported so far. Definitive diagnosis is always made after a histological examination. Apart from an anticipated difficult airway with a risk of airway obstruction upon induction of general anesthesia, anesthetic concerns also include possibility of trauma to the growth and bleeding with attendant risks. We discuss the awake fiberoptic technique used for endotracheal intubation in such a case. This case report highlights the importance of detailed history taking and clinical examination, with emphasis on airway assessment and preoperative planning.

Keywords: Airway management, base of tongue, schwannoma


How to cite this article:
Batra UB, Usha G, Gogia AR. Anesthetic management of schwannoma of the base of the tongue. J Anaesthesiol Clin Pharmacol 2011;27:241-3

How to cite this URL:
Batra UB, Usha G, Gogia AR. Anesthetic management of schwannoma of the base of the tongue. J Anaesthesiol Clin Pharmacol [serial online] 2011 [cited 2019 Aug 19];27:241-3. Available from: http://www.joacp.org/text.asp?2011/27/2/241/81830


   Introduction Top


Schwannoma and neurofibroma are two tumors of the peripheral nerves originating in the nerve sheaths. Schwannoma account for just over 1% of benign tumors reported in oral cavity and the tongue is unanimously considered the most frequent site. [1] We report the airway management of a patient with swelling on the base of tongue which was histopathologically diagnosed to be Schwannoma.


   Case Report Top


A 38-year-old woman presented with a two-year history of swelling at the back of the tongue which had been progressively increasing in size. She complained of fastidious presence, difficulty in swallowing, and change in the quality of the voice. No other positive history was noted. Examination revealed a firm, nontender, globular elevated red mass of about 3 × 4 cm in size arising from the base of the tongue and obscuring the posterior pharyngeal wall. It became more prominent and popped further anterior with the protrusion and depression of the tongue by the patient [Figure 1].
Figure 1: Showing the tumor upon protrusion and depression of tongue

Click here to view


Indirect laryngoscopy could not be accomplished because of the presence of mass. Examination of head and neck was otherwise normal. Laboratory investigations were unremarkable. The contrast-enhanced computed tomography revealed a well-defined round homogenous mass lesion measuring 3.2 × 3.2 × 4.2 cm with smooth margins in the oropharynx extending from the uvula superiorly and up to the level of epiglottis inferiorly. It abutted the base of tongue anteriorly and the posterior pharyngeal wall posteriorly. On either side, it extended to the lateral pharyngeal walls [Figure 2]. There was no evidence of any calcification within the mass.
Figure 2: CT scan of the swelling

Click here to view


Fine needle aspiration cytology from the swelling revealed few epithelial cells. Excision biopsy of the swelling was planned and the patient was referred for preanesthetic check up.

General physical examination was unremarkable. Patient's airway assessment revealed Mallampati score 4 with a normal mouth opening and neck movements. The thyromental and sternomental distances were 7 and 13 cm, respectively. Bilateral nares were patent and there was no deviation of nasal septum. In view of the above mentioned findings, we planned to perform fiberoptic bronchoscope (FOB)-guided awake nasotracheal intubation followed by general anesthesia.

The procedure was explained to the patient and informed consent including consent for tracheostomy, in case of emergency, was taken. Standard preoperative protocol was followed. Injection glycopyrrolate 0.2 mg was administered intramuscularly 45 minutes prior to fiberoptic bronchoscopy. Oxymetazoline nasal drops were instilled in both nostrils. Difficult airway cart was prepared and surgeons were informed to be standby for emergency tracheostomy in case of failure of intubation. Routine monitoring was instituted. Patient was administered 1 mg midazolam and 20 μg fentanyl. After achieving airway anesthesia with nebulization of 4% lignocaine and preoxygenating the patient, a check direct laryngoscopy was attempted to assess the feasibility of passing FOB behind the swelling. The mass was seen to be attached to the right side of the tongue base and some space was there on the left side, adequate for the FOB to be passed. However, we were unable to lift the swelling by the laryngoscope blade. A size 7 cuffed Portex endotracheal tube was loaded on to a flexible FOB, which was then introduced through the right nostril and after its tip was in the oropharynx, the patient was asked to protrude and depress the tongue. The mass then popped out, thus further creating some more space in oropharynx, and then FOB was negotiated from left side of the tumor and guided into the trachea. The endotracheal tube was then passed over the FOB. Tube position was confirmed by bag ventilation and capnography. General anesthesia was then induced with propofol 80 mg and fentanyl 80 μg intravenously and muscle relaxation was achieved with intravenous vecuronium 4 mg. Anesthesia was maintained with isoflurane in oxygen and nitrous oxide. The mass was well encapsulated, arising from the base of the tongue and was extending to the right tonsil. It was not adherent to surrounding structures and good cleavage plane was found, and the complete mass was removed. After the completion of surgery, trachea was extubated uneventfully. The histopathology including immunochemistry of the resected specimen indicated that it was a Schwannoma.


   Discussion Top


Schwannoma or neurilemmoma is a benign encapsulated perineural tumor of neuroectodermal derivation that originates from the Schwann cells of the neural sheath of motor and sensory peripheral nerves. The etiology is unknown and the tumor is usually solitary, benign, smooth-surfaced, slow-growing, and generally asymptomatic or may occasionally cause pain and discomfort. [2] Multiple lesions may occur in association with Von Recklinghausen's disease or Schwannomatosis, a nonhereditary disease characterized by multiple subcutaneous or intradermal schwannoma together with tumors of internal organs.

Schwannoma may develop at any age, but are more common during second and third decades of life and there is no gender predilection. They often originate from the VIIIth cranial nerve. Extracranially, about 25% of all schwannoma are located in the head and neck. [3] Intraoral development is uncommon and they account for just over 1% of benign tumors reported in the oral cavity. The tongue is the most frequent site at this level. [1] The differential diagnosis includes benign lesions such as granular cell tumors, leiomyoma, lymphangioma, lipoma, lingual thyroid, and malignant lesions like squamous-cell carcinoma, cancer of salivary glands, and soft tissue sarcoma. [4] The final diagnosis is always made after a definitive histological examination. [1]

Anesthetic management for surgical excision of schwannoma of the tongue depends upon the location, size, and the surgical approach to provide proper exposure of the tumor and distortion of the airway caused by the tumor. Small and well-encapsulated tumors which do not cause any distortion of the airway anatomy can be approached transorally for surgical excision. Such lesions are excised under local or routine general anesthesia without any complications. However, swellings located at the base of the tongue though asymptomatic, may subsequently be found to have a distorted airway and may cause airway obstruction after the induction of anesthesia. [5] A high index of suspicion should be kept in mind while managing any tumor at the base of tongue. Symptoms such as dysphagia, loss or change in voice, breathlessness, or wheeze should warn the anesthetist of potential airway problem. In a study conducted by Mallampati etal. to predict a clinical sign to predict difficult intubation, it was revealed that the tongue is the single structure in the mouth that affects the accessibility of the laryngeal inlet by direct or indirect laryngoscopy. [6] Therefore, a detailed airway assessment warrants specialist examination with indirect laryngoscopy in addition to a detailed history, examination, and computed tomography (CT) scan of the tumor to predict how easily the airway will be managed or formally intubated.

In our case, the tumor located at the base of the tongue was 3 to 4 cm in size and was extending up to glossopharyngeal fold and obscuring the posterior pharyngeal wall. The patient was having change in quality of voice as well as dysphagia. An indirect laryngoscopy could not be done as the mass was obscuring the view of laryngeal inlet.

We anticipated a difficult airway. Apart from an anticipated difficult airway, our concerns also included possibility of airway obstruction by the tumor following induction of anesthesia leading to a "can't ventilate, can't intubate" situation, trauma and bleeding on attempts at direct laryngoscopy, failure of laryngoscope blade to go behind the tongue, and possibility of laryngospasm. Keeping all these problems in mind, we decided to perform a fiberoptic-guided awake nasotracheal intubation followed by general anesthesia. The advantage of awake fiberoptic intubation is that the anatomy of airway is well preserved and intact muscle tone keeps the airway structures separated from each other, leading to easy visualization of upper airway. In our case, wakefulness aided in maintenance of the airway by retaining the swelling anteriorly and making space for FOB. As the tumor was well encapsulated and nonadherent to adjacent structures, the excision of the tumor did not involve extensive dissection or tongue manipulation. However, we administered 4 mg dexamethasone as a precautionary measure. There was minimal blood loss. Trachea was extubated only after ensuring meticulous hemostasis and complete return of airway reflexes. Patient did not develop any edema of the tissues of oropharynx or upper airway in the postoperative period. The recovery was uneventful.

To conclude, delivery of anesthesia and tracheal intubation, in patients with tumors involving the floor of mouth, is a challenge and requires meticulous preoperative airway assessment including a detailed clinical examination, CT scan, and Magnetic Resonance Imaging to determine the extent of upper airway involvement. It helps the anesthesiologist select correct equipment for airway control and the optimal plan for anesthesia. In such cases, we recommend awake fiberoptic intubation of trachea as a method of choice for performing tracheal intubation.

 
   References Top

1.Gallesio C, Berrone S. Schwannoma located in the tongue: Aclinical case report. Minerva Stomatol 1992;41:583-90.  Back to cited text no. 1
[PUBMED]    
2.Spandow O, Fagerlund M, Bergmark L, Boquist L. Clinical and histopathological features of a large parapharyngeal neurilemmoma located at the base of the tongue. ORL J Otorhinolaryngol Relat Spec 1999;61:25-30.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Hsu YC, Hwang CF, Hsu RF, Kuo FY, Chien CY. Schwannoma (neurilemmoma) of the tongue. Acta Otolaryngol 2006;126:861-5.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Ying YL, Zimmer LA, Myers EN. Base of tongue schwannoma:A case report. Laryngoscope 2006;116:1284-7.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Davies S, Ananthanarayan C, Castro C. Asymptomatic lingual tonsillar hypertrophy and difficult airway management: a report of three cases. Can J Anaesth 2001;48:1020-4.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, FreibergerD, etal. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985;32:429-34.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]


This article has been cited by
1 Procedural Challenges During Intubation in Patients With Oropharyngeal Masses
Yvon F. Bryan,Amelia G. Morgan,Kathleen N. Johnson,Hannah M. Harris,Joseph May,Deborah M. Whelan,Avery Tung
Anesthesia & Analgesia. 2019; 128(6): 1256
[Pubmed] | [DOI]
2 Comprehensive Analyses of Intraoral Benign and Malignant Nerve Sheath Tumors
Yue Song,Jiaan Hu,Yaping Wu,Dongmiao Wang,Yanling Wang,Ping Zhang,Hongbing Jiang,Jianrong Yang,Jie Cheng
Journal of Craniofacial Surgery. 2019; 30(4): e317
[Pubmed] | [DOI]
3 Pectoral nerve block (Pecs block) with sedation for breast conserving surgery without general anesthesia
Eun-Jin Moon,Seung-Beom Kim,Jun-Young Chung,Jeong-Yoon Song,Jae-Woo Yi
Annals of Surgical Treatment and Research. 2017; 93(3): 166
[Pubmed] | [DOI]
4 Intraoperative Techniques for the Plastic Surgeon to Improve Pain Control in Breast Surgery
Gina Farias-Eisner,Kenneth Kao,Judy Pan,Jaco Festekjian,Andrew Gassman
Plastic and Reconstructive Surgery - Global Open. 2017; 5(11): e1522
[Pubmed] | [DOI]
5 Surgical relevance of the lateral costotransverse ligament in relation to the dorsal root ganglion
Anthony V. D’Antoni,Peter G. Collin,Rachel A. Graham,Helena M. Kennedy,Tatiana Ndjatou,Pamela Perez,R. Shane Tubbs,Marios Loukas,Piotr B. Kozlowski,Estomith P. Mtui
Anatomical Science International. 2016;
[Pubmed] | [DOI]
6 Tongue Base Schwannoma
Swati Tandon,Ravi Meher,Aditi Chopra,Anoop Raj,Vikram Wadhwa,Nidhi Mahajan,Avani Jain
Indian Journal of Otolaryngology and Head & Neck Surgery. 2016;
[Pubmed] | [DOI]
7 Ultrasound-Guided Continuous Quadratus Lumborum Block for Postoperative Analgesia in a Pediatric Patient
Arunangshu Chakraborty,Jyotsna Goswami,Viplab Patro
A & A Case Reports. 2015; 4(3): 34
[Pubmed] | [DOI]
8 Combination of continuous paravertebral block and epidural anesthesia in postoperative pain control after esophagectomy
Yukiko Niwa,Masahiko Koike,Koji Torii,Hisaharu Oya,Naoki Iwata,Mitsuro Kanda,Daisuke Kobayashi,Chie Tanaka,Suguru Yamada,Tsutomu Fujii,Goro Nakayama,Hiroyuki Sugimoto,Shuji Nomoto,Michitaka Fujiwara,Yasuhiro Kodera
Esophagus. 2015;
[Pubmed] | [DOI]
9 Spread of dye after single thoracolumbar paravertebral injection in infants
Andrew A. Albokrinov,Ulbolgan A. Fesenko
European Journal of Anaesthesiology. 2014; 31(6): 305
[Pubmed] | [DOI]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
    Introduction
    Case Report
    Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed2223    
    Printed132    
    Emailed1    
    PDF Downloaded324    
    Comments [Add]    
    Cited by others 9    

Recommend this journal