Massive Cystic Hygroma of Neck in an Infant: Overcoming Anaesthetic Challenges
Year: 2026
Type: article
Abstract: Dear Editor, Cystic hygroma is a congenital benign lymphatic malformation caused by blocked lymphatic-venous pathways leading to lymph accumulation in jugular sacs[1] and presents challenges in managing pediatric airway due to huge swelling in front of neck.[2] It can be associated with conditions such as Down’s syndrome, turners syndrome, and cardiac dysfunction.[3] This case details the anesthetic complexities of managing a massive cystic hygroma in an infant, emphasizing the importance of preoperative planning and multidisciplinary approach. A 10-month-old, 5 kg infant presented with a progressive swelling in anterior neck and floor of mouth [Figure 1] causing feeding difficulties and failure to thrive. Preoperative assessment identified a potentially difficult airway due to mass’s size and location and high arch palate. Imaging confirmed that a large cervicofacial multilocular, multiseptated cystic lesion without mediastinal involvement was noted. Preparation included a difficult airway cart, tracheostomy equipment, and invasive lines.Figure 1: Chest X-ray showing no mediastinal involvementAfter confirming adequate nil by mouth status and parental consent, intranasal midazolam 1 mg and ketamine 25 mg were given preoperatively to provide sedation 30 minutes before induction. After shifting the child to operating room, standard monitors were attached and inhalation induction was performed with sevoflurane with 100% O2 maintaining spontaneous ventilation. Initial nasal intubation with 4.5 uncuffed ETT failed due to inadequate visualization. Mask ventilation was resumed with 100% O2 [Figure 2]. Inj. Propofol 5 mg i.v. was given to deepen the anesthesia plane, and repeat laryngoscopy was attempted using Mcintosh blade no. 1, after external laryngeal manipulation (BURP maneuver) bougie guided intubation with 4.5 uncuffed ETT was successfully done, confirmed with End tidal CO2 and auscultation. Under all aseptic precautions, right femoral vein and right radial artery were cannulated. Anesthesia was maintained with 02: air with sevoflurane and surgical procedure proceeded without significant blood loss. At the end of the procedure, after confirmation of adequate respiratory efforts and stable vitals, the patient was extubated on the table. Postoperative monitoring in the pediatric intensive care unit (PICU) ensured no immediate complications.Figure 2: Good mask holding with RBS maskOur patient did not have any difficulty in breathing or stridor. The complete outline of the mass and its extension into the respiratory tract needs to be assessed to formulate an appropriate plan of airway management. Chest X-ray helps to exclude the intrathoracic extension and extent of airway involvement. Tumors located in mediastinum require further evaluation like angiography, CT scan, and fluoroscopy. Difficulties in mask ventilation, laryngoscopy, and intubation were considered in our case because of size and location of the mass. Meticulous preparation, expert guidance helps in easy navigation toward successfully securing the airway. Fiberoptic intubation is ideal, but its availability and considerable amount of expertise is required in an infant. Video laryngoscope was not available in our institute. Emergency tracheostomy under local anesthesia remains an option if necessary. Maintaining spontaneous ventilation during induction is recommended to prevent airway collapse due to mass weight. Preoperative nasal ketamine and midazolam helped to keep our infant calm.[4] The visualization of epiglottis is difficult in such cases; thus, check laryngoscopy was performed under sevoflurane. External laryngeal manipulation, pulling of mass manually,[5] bougie, sand McCoy laryngoscopes may help. Maintaining the airway is also important as vigorous surgical retractions may result in accidental extubation or endobronchial intubation. Postresection, the decision of extubation is crucial due to risks such as supraglottic oedema, tongue involvement, and hematoma formation. The need for elective ventilation must be considered if such situation arises. Intraoperative hemodynamic monitoring and blood loss control are critical, as even small blood loss can lead to drastic drop in oxygen carrying capacity without causing significant hemodynamic variability, which may further lead to delay in extubation. This case underscores that even with a giant cystic hygroma, airway management is achievable through comprehensive planning and multidisciplinary collaboration among pediatric surgeons, otolaryngologist, and anesthesiologist. Data availability statement The data supporting the findings of this study are available within the article. As this is a case report, all relevant clinical data have been included in the manuscript. Additional data are not publicly available to maintain patient confidentiality but can be provided by the corresponding author upon reasonable request and with appropriate ethical approval. Author contributions SK, VS, SS: Conceptualization. SS: Data Collection. SS, SJ: Data Analysis. SS, SK: First draft of the manuscript. SK, VS, SS, SJ: Approved this manuscript for submission. Declaration of patient consent We certify that we have obtained all appropriate consent from the parents as our patient was a minor. The parents have given the consent for the image and other clinical information of the patient to be reported to the journal. They understand that their names and initials will not be published, and due effort has been made to conceal the identity of the patient, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Language: English
Subfield: Anesthesiology and Pain Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W7130506309