Anterior mediastinal masses in children

Anterior mediastinal masses may present life-threatening challenges for the anesthesiologist, particularly in children. Children with symptoms referable to the respiratory involvement may present with dyspnea, orthopnea, or pleuritic chest pain. Those with symptoms referable to cardiovascular involvement may present with syncope, shortness of breath with exertion and in certain positions, and swelling in the face. Chest x-rays, CAT scans, and echocardiography are commonly used to investigate these masses. The more common tumors in the anterior mediastinum are known by the four “T”s: thymoma, teratoma, thyroid, and terrible lymphoma. T-cell lymphomas represent the most rapid growing tumors with a doubling time of 12 hours. These tumors may invaginate or compress adjacent structures, such as the trachea, causing tracheomalacia and tracheal narrowing and/or may compress the pulmonary artery and right atrium, infiltrate the pericardium, and restrict the superior vena cava, thereby compromising cardiac output. The key strategy when planning these cases is to consider the type of anesthetic, spontaneous ventilation, and the position of the child. Local anesthesia, sedation, or general anesthesia is suitable. Local anesthesia with sedation may be used in cooperative older children. General anesthesia should be accompanied by spontaneous ventilation. Muscle relaxants are proscribed. Children may not tolerate the supine position, especially after induction of anesthesia; turning the child to the left decubitus or prone position restores ventilation and cardiac output. The key strategy to restore cardiorespiratory homeostasis when the anesthetized child with an anterior mediastinal tumor begins to deteriorate is to turn them to the lateral decubitus or prone position.