© Georg Thieme Verlag KG Stuttgart · New York
Management of Anterior Mediastinal Masses in Children
received February 16, 2011
accepted after revision April 29, 2011
12 July 2011 (eFirst)
Background: Children with anterior mediastinal masses are at risk for life-threatening airway compromise during anesthesia, and can present a diagnostic and management challenge for pediatric surgeons.
Methods: We performed a retrospective chart review of all children presenting with an anterior mediastinal mass from 1994–2009. Parameters studied included demographics, historical and physical findings at diagnosis, radiographic evidence of airway compression, diagnostic studies, diagnosis, and complications.
Results: There were 26 patients with anterior mediastinal masses over a 15-year period. The mean age was 11.3 years, and there were no gender differences. The diagnoses were lymphoma (62%, 16/26), leukemia (15%, 4/26), and other (23%, 6/26). Diagnosis was made by CBC/peripheral smear in 2/4 patients with leukemia, by bone marrow biopsy in 2/4 patients with leukemia, by thoracentesis in 3/16 patients with lymphoma, by lymph node biopsies in 6/16 patients with lymphoma, and by biopsy of a mediastinal mass in 7/16 patients with lymphoma and in 6/6 patients with other diagnoses. Radiographic evidence of airway compression was seen in 62% (16/26) of children. Only 12% (3/26) had a tracheal cross-sectional area (TCA) <50%. Correlation of symptoms with anatomical airway obstruction or complications was poor. Pulmonary function studies were obtained in 38%, 10/26 children. Only 2 children had a PEFR (peak expiratory flow rate) <50% predicted. This data also correlated poorly with anatomical airway obstruction or complications. 3 patients had anesthesia-related complications: one desaturation during induction prior to median sternotomy, one with significant desaturation and bradycardia during biopsy under local anesthesia with minimal sedation, and one with prolonged (5 days) mechanical ventilation after general anesthesia. 2 of these patients had a TCA <50%, and 2 had SVC obstructions. There were no anesthesia-related deaths, and the overall survival was 85% (22/26).
Conclusion: Anterior mediastinal masses in children should be approached in a step-wise fashion with multi-disciplinary involvement, starting with the least invasive techniques and progressing cautiously. The surgeon should have a well-defined and preoperatively established contingency plan if these children require general anesthesia for diagnosis.
respiratory failure - lymphoma - anesthetic complications - mediastinal mass - leukemia
- 1 Shamberger RC. Preanesthetic evaluation of children with anterior mediastinal masses. Semin Pediatr Surg. 1999; 8 61-68
- 2 Azizkhan RG, Dudgeon DL, Buck JR. et al . Life-threatening airway obstruction as a complication to the management of mediastinal masses in children. J Pediatr Surg. 1985; 20 816-822
- 3 Slinger P, Karsli C. Management of the patient with a large anterior mediastinal mass: recurring myths. Curr Opin Anaesthesiol. 2007; 20 1-3
- 4 Turoff RD, Gomez GA, Berjian R. et al . Postoperative respiratory complications in patients with Hodgkin's disease: relationship to the size of the mediastinal tumor. Eur J Cancer Clin Oncol. 1985; 21 1043-1046
- 5 King RM, Telander RL, Smithson WA. et al . Primary mediastinal tumors in children. J Pediatr Surg. 1982; 17 512-520
- 6 Shamberger RC, Holzman RS, Griscom NT. et al . Prospective evaluation by computed tomography and pulmonary function tests of children with mediastinal masses. Surgery. 1995; 118 468-471
- 7 Hnatiuk OW, Corcoran PC, Sierra A. Spirometry in surgery for anterior mediastinal masses. Chest. 2001; 120 1152-1156
- 8 Torchio R, Gulotta C, Perboni A. et al . Orthopnea and tidal expiratory flow limitation in patients with euthyroid goiter. Chest. 2003; 124 133-140
- 9 Miller RD, Hyatt RE. Evaluation of obstructing lesions of the trachea and larynx by flow-volume loops. Am Rev Respir Dis. 1973; 108 475-481
- 10 Anghelescu DL, Burgoyne LL, Liu T. et al . Clinical and diagnostic imaging findings predict anesthetic complications in children presenting with malignant mediastinal masses. Paediatr Anaesth. 2007; 17 1090-1098
- 11 Lam JCM, Chui CH, Jacobsen AS. et al . When is a mediastinal mass critical in a child? An analysis of 29 patients. Pediatr Surg Int. 2004; 20 180-184
- 12 Freud E, Ben-Ari J, Schonfeld T. et al . Mediastinal tumors in children: a single institution experience. Clin Pediatr (Phila). 2002; 41 219-223
- 13 Stricker PA, Gurnaney HG, Litman RS. Anesthetic management of children with an anterior mediastinal mass. J Clin Anesth. 2010; 22 159-163
- 14 Hack HA, Wright NB, Wynn RF. The anesthetic management of children with anterior mediastinal masses. Anaesthesia. 2008; 63 837-846
- 15 Lerman J. Anterior mediastinal masses in children. Semin Anesth. 2007; 26 133-140
Dr. Charles L. Snyder, MD
Children's Mercy Hosptial
Department of Surgery
24th and Gillham Rd
United States 64108
Phone: + 1 816 234 35 76
Fax: + 1 913 983 63 71