Header bg
  • Users Online: 104
  • Print this page
  • Email this page
Header bg


 
 
Table of Contents
CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 128-131

Airway management of giant occipital meningoencephalocele removal


Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Bali, Indonesia

Date of Submission17-Oct-2020
Date of Decision14-Dec-2020
Date of Acceptance18-Dec-2020
Date of Web Publication16-Apr-2021

Correspondence Address:
Dr. Christopher Ryalino
Faculty of Medicine, Udayana University, Jl. PB Sudirman, Denpasar 80232, Bali
Indonesia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjoa.bjoa_229_20

Rights and Permissions
  Abstract 


Cephalocele refers to defects in the skull and dura with extensions from intracranial to extracranial structures. Cephalocele is divided into four types which are meningoencephalocele, meningocele, atretic encephalocele, and gliocele. Encephalocele is a head's contents herniation through a defect in the skull. Meningocele is a herniation sac that contains cerebrospinal fluid and nerve elements. Meningoencephalocele is a prominent herniation of the meningeal part, nerve elements, and brain tissue in a sac that protrudes through a defect in the skull. In Southeast Asia, the incidence of meningoencephalocele is estimated to occur in 1 in 5000 live births. The occipital bone is the most common location of cephalocele. The neurological outcome of malformations that occur depends on the size of the sac formed, the nerve tissue involved, hydrocephalus, related infections, and other pathological conditions involved. Perioperative preparation must be well made by an anesthesiologist based on airway management, fluid balance, and hypothermia prevention. The main challenge of anesthesia in the management of the occipital meningoencephalocele is securing the airway. Pediatric patients have low functional reserve volume, and failure of tracheal intubation can cause hypoxemia, bradycardia, and even heart attacks. Improper positioning and limited neck extension can complicate endotracheal intubation.

Keywords: Airway, difficult, intubation, pediatric, ventilation


How to cite this article:
Agung Senapathi TG, Suandrianno Y, Sukrana Sidemen I G, Ryalino C, Pradhana AP. Airway management of giant occipital meningoencephalocele removal. Bali J Anaesthesiol 2021;5:128-31

How to cite this URL:
Agung Senapathi TG, Suandrianno Y, Sukrana Sidemen I G, Ryalino C, Pradhana AP. Airway management of giant occipital meningoencephalocele removal. Bali J Anaesthesiol [serial online] 2021 [cited 2021 Jun 23];5:128-31. Available from: https://www.bjoaonline.com/text.asp?2021/5/2/128/313889




  Introduction Top


Cephalocele refers to a defect in the skull and dura with extensions from the intracranial to extracranial structures. Cephalocele is divided into four types which are meningoencephalocele, meningocele, atretic encephalocele, and gliocele. Encephalocele is a head's contents herniation through a defect in the torn bone. Meningocele is a herniation consists of cerebrospinal fluid (CSF) and nerve elements. Meningoencephalocele is a protruding herniation of the meningeal, nerve elements, and brain tissue in a sac that protrudes through a defect in the skull bone.[1],[2]

In Southeast Asia, the incidence of meningoencephalocele is estimated to occur in 1 in 5000 live births.[2] The occipital bone becomes the most common site for cephalocele. The neurological outcome of the malformation depends on the size of the sac formed, nerve tissue involved, hydrocephalus, associated infection, and other pathological conditions involved in the anomaly.


  Case Report Top


A 5-month-girl was admitted to the hospital due to a lump on the back of her head since her birth. The lump was soft, attached to the back of the head, and enlarged along with the growth of the child. The patient had no complaints of fever, nausea, vomiting, or seizures.

The patient could not raise her head or turn over because of the lump on the back of her head. The patient was born twin, with birth weight of 2300 g. The patient had no allergy history. Based on physical examination, the patient was a baby girl with a current bodyweight of 6 kg, body length of 60 cm. No other congenital abnormalities were found in the patient. Complete blood count revealed leukocytosis (15.14 × 103/μL) and mild anemia (9.55 g/dL). Other laboratory test results were unremarkable.

The patient was subjected to a computed tomography scan of the head with the results of the occipital meningoencephalocele measuring 16.7 cm × 15.6 cm × 16.2 cm, noncommunicant hydrocephalus, and midline shift to the left. The babygram X-ray showed no abnormality [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Figure 1: Clinical presentation

Click here to view
Figure 2: Preoperative head computed tomography scan

Click here to view
Figure 3: Intraoperative finding (preclosure)

Click here to view
Figure 4: Postoperative presentation

Click here to view


The patient was then given 0.5 mg midazolam intravenous (IV) as premedication at the preparation room. In the operating room, the patient was positioned in the right lateral decubitus position. Patient's electrocardiogram, peripheral oxygen saturation, and end-tidal CO2 were measured.

The patient was then preoxygenated with 100% O2 for 5 min and given 10 mcg fentanyl as analgesic. The patient was then induced using sevoflurane and after patency of the airway was confirmed, 40 mg IV atracurium was given. After 5 min, the patient then was intubated using noncuffed ETT 3.5.

The patient was then positioned to prone position with pads that had been set in advance. During the operation, the depth of the anesthesia was then maintained using sevoflurane 2.5 vol% and FiO2 60% with a flow of 6 L/min, 1 mcg fentanyl every 45–60 min, and 1 mg atracurium every 30–45 min.

During the period, vital signs were measured. The patient's heart rate ranged from 130 to 145 beats per minute with normal sinus rhythm, respiratory rate 37–39 breaths per minute, peripheral oxygen saturation 98%–100%, and EtCO2 29–34 cmH2O.

The operation was accomplished in 2 h and 45 min. After the operation was completed, the patient was turned to the supine position, extubated, and transferred to pediatric intensive care unit (PICU). The patient was given 40 mcg fentanyl in 10 mL of 0.9% NaCl at a rate of 0.4 mL/h and 75 mg IV paracetamol every 8 h as a postoperative analgesic. The patient was hospitalized in the PICU for 3 days, then the patient was transferred to the ward and hospitalized for another 2 days.


  Discussion Top


Airway management in neonates and infants with large neck masses such as large meningoencephalocele is mostly challenging. The occipital meningoencephalocele likely presents a high degree of difficulty to anesthetists due to inadequate head extension and the inability to lie down in a supine position, especially in neonates and infants, which make the optimal position for intubation becomes difficult to be achieved.

Meningoencephalocele refers to a hernial protrusion of the meninges and nerve elements in the sac through a defect that forms in the skull. About 75% of the encephalocele is in the occipital area. Children with meningoencephalocele tend to have varying degrees of sensory and motor deficits. Common associated congenital defects are clubfoot, hydrocephalus, exstrophy of the bladder (ectopia vesicae), uterine prolapse, Klippel - Feil syndrome, and congenital heart disease.[1],[2]

Perioperative preparation should be properly made by an anesthetist based on airway management, fluid balance, and prevention of hypothermia. The main challenge in managing the occipital meningoencephalocele is securing the airway. Pediatric patients have a low functional reserve volume which makes a failure tracheal intubation can easily lead to hypoxemia, bradycardia, and even cardiac arrest.[2],[3],[4] Difficulty in positioning and patient's limited neck extension can complicate endotracheal intubation. In managing most of meningoencephalocele patients, mask ventilation and tracheal intubation can be performed in the lateral or supine position with the sac protected either by lifting or traditionally using a donut-shaped bearing.

Another method is to place the patient's head at the end of the table with an assistant holding the patient's head while another assistant stabilizes the body of the patient. This method will require at least two assistants.[4],[5] In another case report, a technique for airway management using a set of simple foam pillows was described [Figure 5]. With this approach, only one person is needed to manage the airway.[6]
Figure 5: Foam pillows configuration. 1. Square pillow, 2–4. Adjustable cushions made of sterile blanket, 5. Adjustable hole which can be adjusted based on patient's head

Click here to view


In this case report, the meningoencephalocele which is larger than the head made a donut-shaped pillow to holding the patient's head or an assistant holding the patient's head at the end of the table rendered impractical and at high risk of harming the patient. Therefore, a lateral intubation trial was performed in this patient.

The lateral intubation technique was chosen with the consideration that the patient's meningoencephalocele was soft and could be manipulated to assist the intubation process. Decompression of the encephalocele sac using a needle and sterile technique had been considered as an alternative approach to anticipate difficult intubation. However, rapid decompression of the ventricular system could lead to fatal complications such as cardiac arrest due to traction of the pathways of brain neurons which involve the brainstem's nucleus.[7],[8],[9]

Prior to the administration of neuromuscular blocking agents, adequate positive ventilation should be confirmed.[10] Muscle relaxant agent was injected after head stabilization, the right lateral position of the patient, and adequate positive pressure ventilation with facemask was achieved. Long-acting muscle relaxants should not be administered in case the surgeon planned to use nerve stimulator to identify nerve functional elements.[2],[10] In this case, due to the absence of the nerve stimulation procedure, relaxation of the patient's muscles was maintained using atracurium intraoperatively.

Another intraoperative problem is neurological involvement in the form of seizures which can occur immediately after the surgery. Intense monitoring is required to estimate blood loss and adequate replacement. The large amount of discharged CSF can cause volume and electrolyte disturbance which will require perioperative therapy.[7]

In infants with encephalocele, dysfunction of autonomic control below defective levels makes the conservation of body temperature an important issue. Thus, special attention to blood loss, maintenance of the body temperature, prone positioning, and associated complications, and maintenance of the endotracheal tube must be given.


  Conclusion Top


The perioperative management of a patient with giant meningoencephalocele can be challenging for anesthetists and neurosurgeons. The management of a meningoencephalocele case consists of the search for other congenital abnormalities, managing the airway, and intraoperative care which are proper positioning, monitoring of the body temperature, and replacement of blood lost during surgery. Patients with giant meningoencephalocele should be treated carefully through an interdisciplinary approach. Careful planning and perioperative management are essential for successful anesthetic management for these patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pahuja H, Deshmukh S, Lande S, Palsodkar S, Bhure A. Anaesthetic management of neonate with giant occipital meningoencephalocele: Case report. Egypt J Anaesth 2015;31:331-4.  Back to cited text no. 1
    
2.
Miller Ronald D. Miller's Anesthesia. 9th ed. Philadelphia, PA: Churcill Livingstone/Elsevier; 2019.  Back to cited text no. 2
    
3.
Ghritlaharey RK. A brief review of giant occipital encephalocele. J Neurosci Rural Pract 2018;9:455-6.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Jain K, Sethi SK, Jain N, Patodi V. Anaesthetic management of a huge occipital meningoencephalocele in a 14 days old neonate. Ain-Shams J Anesthesiol 2018;10:13.[doi: 10.1186/s42077-018-0005-7].  Back to cited text no. 4
    
5.
Neeta S, Upadya M, Pachala SS. Anesthetic management of a newborn with occipital meningocele for magnetic resonance imaging. Anesth Essays Res 2015;9:238-40.  Back to cited text no. 5
  [Full text]  
6.
Naik V, Marulasiddappa V, Gowda Naveen MA, Pai SB, Bysani P, Amreesh SB. Giant encephalocoele: A rare case report and review of literature. Asian J Neurosurg 2019;14:289-91.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Sethi, C, Kumar R, Gaur S. Airway management of a large giant occipital encephalocele in a neonate – An anaesthetic challenge. Br J Pharm Med Res 2019;4:2127-31.  Back to cited text no. 7
    
8.
Kothare P, Khushboo D. Anaesthesia approach to a six month old child of meningomyelocele with hydrocephalus and Arnold Chiari malformation. JMed Clin Res 2019;7:774-8.  Back to cited text no. 8
    
9.
Mahajan C, Rath GP, Bithal PK, Mahapatra AK. Perioperative management of children with giant encephalocele: A clinical report of 29 cases. J Neurosurg Anesthesiol 2017;29:322-9.  Back to cited text no. 9
    
10.
Karim HMR, Yunus M, Barman A, Kakati SD, Dey S. Adjustable horseshoe headrest as a positioningadjunct in airway management for a giant occipital encephalocele. Open Anesthesia J 2017;11:83-7.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed188    
    Printed16    
    Emailed0    
    PDF Downloaded17    
    Comments [Add]    

Recommend this journal