CT QUANTITATION OF TRACHEAL CROSS-SECTIONAL AREA AS A GUIDE TO THE SURGICAL AND ANESTHETIC MANAGEMENT OF CHILDREN WITH ANTERIOR MEDIASTINAL MASSES

Pediatric patients presenting with anterior mediastinal masses between January 1980 and November 1988 were reviewed to assess the correlation between tracheal cross-sectional area and anesthetic risks. Forty-two patients had evaluable computed tomography (CT) scans and underwent a surgical procedure. Thirty-four patients had Hodgkin's disease, six had non-Hodgkin's lymphoma, and two had mediastinal teratoma. Tracheal cross-sectional areas were >75% of expected in 19 cases, >50% to 75% in 16 cases, >25% to 50% in five cases, and ≤25% in two cases. The presence or extent of symptoms did not correlate well with the degree of tracheal narrowing shown by CT scan except for orthopnea. Local anesthesia was used primarily in patients with significant tracheal narrowing (tracheal size was ≤56% in 5 of 6 patients). General anesthesia with spontaneous ventilation by mask was performed in four patients with tracheal areas of 33%, 73%, 76%, and 98% of expected. General endotracheal anesthesia was utilized in the remaining 32 patients, only three of whom had tracheal areas of less than 50% of expected (down to 30%, 26%, and 24% of expected) and one received preoperative radio-therapy (26%). None of these 32 patients had symptoms of orthopnea or dyspnea at rest, and only one had dyspnea on exertion. All tolerated anesthesia without difficulty. No patient in this series suffered respiratory or cardiovascular collapse during surgery. Adequate biopsy material was obtained in all cases. This retrospective evaluation of tracheal areas suggests that general endotracheal anesthesia is safe in a patient with an anterior mediastinal mass and a tracheal cross-sectional area of ≥50% of expected, with 29 patients undergoing uneventful general endotracheal anesthesia in this group. More severe degrees of tracheal narrowing require caution. The absence of major complications in this series makes definition of the "critical" tracheal area difficult. However, it is of note that local anesthesia (3 patients), spontaneous ventilation (1 patient), or preoperative radiation (1 patient) were used in five of the seven patients with less than 50% of expected tracheal area. Although these patients were identified initially by clinical symptoms, we urge their identification based on CT evaluation because they are the group of patients most susceptible to airway compromise. © 1991.