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A simple approach to airway management for a giant sublingual dermoid cyst

Annamalai University, Tamilnadu, India, E-mail: vrthiran{at}yahoo.co.in

To the Editor:

Sublingual dermoid cysts are uncommon and account for less than 1% of cystic intra-oral lesions.¹ Fewer than 225 cases have been reported in the literature.^1–4 Giant size sublingual dermoid cysts are extremely rare and pose considerable technical challenges to the anesthesiologist and surgeon.^2,3 Huge cysts may fill the entire oral cavity and render tracheal intubation extremely difficult or impossible. Suggested airway management strategies include blind nasotracheal intubation, fibreoptic endoscope-guided intubation, laryngeal mask airway and preliminary tracheostomy. ^1–5 These approaches are technically demanding and require sophisticated endoscopes which are not universally available. Preliminary tracheostomy significantly increases morbidity. Although excision under local anesthesia with monitored anesthesia care has been reported in a few cases, there is a risk of intraoperative pulmonary aspiration. We herein describe a safe and simple technique of airway management in such cases.

We recently treated a five-year-old boy who presented with a massive sublingual dermoid cyst of several years’ duration (Figure 1). The cyst measured 10 x 10 cm and was located within the floor of the patient’s mouth displacing his tongue to the left side. The cyst filled the entire oral cavity and prevented closure of the mouth. Articulation and mastication were impossible; yet he did not have respiratory distress at the time of presentation. A sublingual dermoid cyst was diagnosed and surgical excision was planned. Prior to induction of anesthesia the cyst was completely decompressed by aspiration of its contents using a 16G needle. Approximately 150 mL of thick brown oily fluid was aspirated, resulting in dramatic collapse of the cyst (Figure 2). At this stage, the airway assessment revealed normal mouth opening with a Mallampati class 1 airway. Accordingly, it was deemed appropriate to proceed with general anesthesia following application of routine monitors. Following induction with thiopentone sodium 75 mg iv (5 mg·kg^–1) and atracurium 7.5 mg iv (0.5 mg·kg^–1), direct laryngoscopy revealed a laryngeal grade 1 view (Cormack and Lehane classification), and the patient’s trachea was intubated with a # 5 oral endotracheal tube. The patient’s lungs were ventilated and anesthesia and surgery proceeded without incident. Following complete excision of the lesion, the patient’s recovery was uneventful.

View larger version (96K): [in this window] [in a new window]   FIGURE 1 Giant sublingual dermoid cyst (before needle aspiration).

View larger version (113K): [in this window] [in a new window]   FIGURE 2 Completely collapsed cyst (after needle aspiration) resulting in a roomy oral cavity.

Huge intra-oral cysts also hinder surgical access. Therefore, extra-oral submental access, median glossotomy, extended median glossotomy and mandibulotomy approaches have been described.^2–4 They increase morbidity and are cosmetically unacceptable. The case reported herein illustrates that preanesthetic aspiration improves surgical access, thereby facilitating complete transoral excision of giant cysts.

We wish to caution that needle aspiration of cyst is only a temporizing measure and it cannot be the definitive treatment. Although aspiration may occasionally fail due to the pultaceous nature of cyst content,¹ we emphasize that it is worth attempting in every case. We extrapolate that this technique may be applicable in any huge cystic lesion of the oral cavity⁵ irrespective of its pathology.

Footnotes

Accepted for publication August 15, 2006.

References

1 King RC, Smith BR, Burk JL. Dermoid cyst in the floor of the mouth. Review of the literature and case reports. Oral Surg Oral Med Oral Pathol 1994; 78: 567–76.[Medline]

2 Pashley NR. Massive dermoid cysts of the floor of the mouth in children. Int J Pediatr Otorhinolaryngol 1981; 3: 355–63.[Medline]

3 Di Francesco A, Chiapasco M, Biglioli F, Ancona D. Intraoral approach to large dermoid cysts of the floor of the mouth: a technical note. Int J Oral Maxillofac Surg 1995; 24: 233–5.[Medline]

4 Longo F, Maremonti P, Mangone GM, De Maria G, Califano L. Midline (dermoid) cysts of the floor of the mouth: report of 16 cases and review of surgical techniques. Plast Reconstr Surg 2003; 112: 1560–5.[Medline]

5 Kumar KV, Joshi M, Vishwanath N, Akhtar T, Oak SN. Neonatal lingual gastric duplication cyst: a rare case report. J Indian Assoc Pediatr Surg 2006; 11: 97–8.

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