A three-year-old, 11 kg child with continuous salivary drooling, swallowing difficulty, and poor speech had a 5 × 6 × 10 cm congenital cystic hygroma of tongue which prevented closure of mouth and pushed dorsum of tongue toward palate. He could sleep comfortably in all positions without snoring. Both nostrils were patent. No other swelling or lymph nodes were noticed. A CT scan revealed minimal mass effect on naso/oropharynx. Coexisting anomalies were ruled out. 

Difficult airway cart, tongue stitch, and tracheostomy set were kept ready. Following 10-min preoxygenation and intravenous glycopyrrolate, anesthesia was induced with sevoflurane in oxygen with circular silicon facemask no. 2 initially. Anesthesia was maintained later through nasopharyngeal airway (NPA) via left nostril attached to Jackson Rees (JR) circuit with sevoflurane in 50-50 oxygen-nitrous oxide mixture. Ventilation was possible with jaw thrust with the head turned to one side. Propofol was infused at 4 mg/kg/h. A pediatric fiberoptic bronchoscope (FOB) (Olympus ENF Type P2 model no. 2005366: 3.5 mm diameter, 30 cm working length, 120° angle of view, angulation 130°/130° up/down without suction channel) charged with lubricated 5 mm PVC uncuffed endotracheal tube (ETT), was guided in trachea. Tongue with the cyst was gently displaced using tongue depressor and throat was packed carefully. Subsequent general anesthesia and manual ventilation was uneventful.

Following drainage of 20 mL pus, marsupialization of the cyst wall was done. Check laryngoscopy at the end of surgery ruled out any other hygromas. A tongue stitch was left behind for 48 h. There was no evidence of airway obstruction, tongue edema, bleeding, and desaturation. Orals were started after 48 h. Antibiotics and serratiopeptidase tablets were continued for 5 days. 

Direct laryngoscopic intubation under ketamine anesthesia, NPA, and tracheostomy have been used occasionally. ^[1],[2],[3] Tracheostomy requires anesthesia. In cooperative adults and older children options like fiberoptic bronchoscopic, blind nasal and retrograde intubation are available. Lack of strong airway reflexes permits nasal FOB and direct laryngoscopy in an awake neonate. However, the same is impossible in 2- to 6-year-old children where general inhalational anesthesia with spontaneous breathing is the preferred technique. 

In the case of nonavailability of FOB, blind nasal intubation with or without guide and retrograde intubation in spontaneously breathing patient under general anesthesia have been tried.^[4],[5] Though an ideal technique, pediatric bronchoscopic intubation is time consuming and needs experience, skill, expert assistance, proper size of FOB, smooth inhalational induction, deep plane of anesthesia, and maintenance of spontaneous ventilation. In the absence of Patil Syracuse endoscopic facemask, we used NPA via other nostril for administration of anesthetic gases. Since our patient could be ventilated, propofol was used to improve depth of anesthesia. 

Pediatric FOB has an external diameter of 2.2-5.8 mm. The larger scopes offer more directional control with suction channel to remove secretions, administer local anesthetics, insufflate oxygen, or insert flexible guide wire. However, they cannot be negotiated into the larynx of younger children. One can use them to visualize glottis and pass a guide through its suction channel over which ETT can be threaded.^[6] In the absence of suction channel, passing FOB through one nostril and negotiating ETT through another nostril is possible.^[7] Large ETT are difficult to negotiate over smaller FOBs which are floppy, with short focal length and without suction port, ultimately demanding higher skill. Fortunately, we had a 3.5 mm FOB over which 5 mm ETT could be negotiated. 

FOB is a safe and good option for large intraoral swelling in children, provided that intubation is done under a deep plane of anesthesia. Needs and characteristics of the patient and FOB decide the specific technique to be used.

References 

1. Esmaeili MR, Razavi SS, Abbasi HR, Tabatabaii SM, Sheikhi MA, Sheikhi MA. Cystic hygroma: Anesthetic considerations and review. J Res Med Sci 2009;14:191-5.   [PUBMED]      
2. Macdonald DJ. Cystic Hygroma: An anaesthetic and surgical problem. Anaesthesia 1966; 21:66-71.  [PUBMED]    
3. Meher R, Garg A, Raj A, Singh I. Lymphangioma of Tongue. Internet J Otorhinolaryngology [serial on the Internet]. 2005; 3.
4. Arora MK, Karamchandani K, Trikha A. Use of a gum elastic bougie to facilitate blind nasotracheal intubation in children: A series of three cases. Anaesthesia 2006;61:291-4.    [PUBMED]  [FULLTEXT]  
5. Borland LM, Swan DM, Leff S. Difficult pediatric endotracheal inubation: A new approach to retrograde technique. Anesthesiology 1981;55:577-8.  
6. Stiles CM. A flexible fiberoptic bronchoscope for endotracheal intubation of infants. Anesth Analg 1974;53:1017-9.   [PUBMED]    
7. Alfery DD, Ward CF, Harwood IR, Mannino FL. Airway management for a neonate with congenital fusion of jaws. Anesthesiology 1979;51:340-2.   [PUBMED]  [FULLTEXT]