THE image depicts an anterior mediastinal mass in a 4-yr-old who presented with numbness in the left arm. A large soft tissue mass can be seen in the anterior mediastinum. The mass extended into the neck and displaced the great vessels in the mediastinum and major vessels in the left neck. The airway and thyroid were deviated toward the right. The trachea was narrowed slightly at its midportion. The overall size of the mass was 12 × 5 × 5 cm. The patient presented for biopsy of the mass. Despite the impressive magnetic resonance imaging scan, the child preoperatively had no sign of airway obstruction. For the procedure, anesthesia was induced with propofol, and a laryngeal mask airway was inserted. Anesthesia maintenance was with a propofol infusion with fentanyl supplementation while the patient breathed spontaneously with the head elevated. The procedure was uneventful. The pathologic diagnosis was stage 3 T-cell lymphoplastic non-Hodgkin lymphoma with starry sky macrophages.

Patients, particularly children, with anterior mediastinal masses can have pulmonary as well as cardiac collapse.1,2In a series of 98 adults who underwent 105 procedures, no patient during surgery had airway obstruction.3Infants and small children, though, have airways that are more compressible, and they may be more susceptible than adults to extrinsic airway obstruction. Preoperatively, patients should be evaluated for extension of the tumor to determine whether the tumor affects structures that can lead to respiratory and or hemodynamic instability.4Although there are risks in anesthetizing children with mediastinal masses, it is also important that an accurate tissue diagnosis can be obtained so appropriate therapy can be instituted. If airway obstruction preoperatively is not severe, anesthesia should generally be safe.5Spontaneous respiration is essential to maintain negative intrathoracic pressure and prevent compression of anterior mediastinal structures.6It is advisable, then, that paralysis should be avoided. Although the use of laryngeal mask airways has been described as part of the anesthetic management of patients with a mediastinal mass, an endotracheal tube can alleviate obstruction due to a mediastinal mass.7 

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