LETTERS TO EDITOR – Anesthetic Management of clival chordoma with retropharyngeal extension: Importance of imaging
Abstract
Dear Editor,
Chordomas are rare but usually aggressive tumors originating from embryonic remnants of the primitive notochord which are usually extradural and induce bone destruction.1 Although 35% occur in the skull base, they represent only 0.1% of all skull base tumors.2
We emphasize on the importance of as specialized imaging techniques for planning definitive airway management which will lead to better perioperative outcome.
A 45 year old,148-cm,52 kg, ASA II lady was presented with history of progressively increasing neck pain for 1 year, which aggravates on neck flexion and bilateral hard of hearing. Preoperative evaluation was satisfactory except for the involvement of XI and XII cranial nerves. As trans-oral approach was planned, we opted for an awake fiberoptic nasal intubation with tracheostomy backup in case of failed intubation. Patient was explained about the procedure and consent obtained. Pre-induction monitoring included electrocardiogram (ECG) lead II and V, noninvasive blood pressure (NIBP), heart rate (HR) and peripheral oxygen saturation (SpO2). Venous access was established by using two 16G cannula. She received intravenous midazolam (1.5 mg), fentanyl (100 µg) and propofol infusion @ 100-150 mcg/kg/min. During fibreoptic intubation it was impossible to pass the scope beyond the nasopharynx due to an obstruction, so procedure was abandoned and surgical tracheostomy was performed under monitored anesthesia care. Radiographic review showed that the lesion has filled the nasopharyngeal space, obstructing the passage of a flexible fibreoptic scope (Fig.1). Following tracheostomy, anesthesia was induced with propofol (2.5 mg/kg), vecuronium bromide (0.1 mg/kg) and the circuit was connected to the tracheostomy tube. Anesthesia was maintained with Air:O2 :: 50:50, isoflurane 1-2%, vecuronium infusion 1 mcg/kg/min infusion and fentanyl infusion 2 mcg/kg/hr. Surgery was performed in prone position followed by supine position and rest of the intraoperative period was uneventful. The duration of surgery was 11 hrs. Patient was shifted to neurosurgical ICU for elective ventilation and decannulated on fourth postoperative day.
