Pediatric

1. A case presentation of
pediatric cystic hygroma
Resident- Razi shahid
Moderater- Sir Dr Mukesh Kumar Prasad

2. Chief Complaints
• Patient - Harshali daughter of MrSandeep Kumar
• Age- 2 years Female
• Chief complaints-
• Sudden Enlargment of swelling in Neck 4 days
• Drooling of Saliva 4 days

3. Histroy of presenting Illness
• As stated by the mother of the patient , she was apparently
asymptomatic 4 days back when she developed sudden enlargement
of swelling . The swelling was present on left side of neck below jaw ,
size was small, swelling was soft and not painful.
• Patient also had drooling of saliva while she is awake and sitting.
• No H/O suggestive of fever, cough, snoring, difficulty in breathing,
and allergies.
• Previously patient had undergone for surgery for neck swelling at
18th day of birth under general anaesthesia.

4. • No significant antenatal history, All trimester were uneventful.
• No history of any congenital anomaly in family.
• All Developmental milestones were normal.
• Immunized as per schedule.
• Dietary requirement is adequate.
• Bowel and Bladder habits Normal.

5. General Examination
• General condition- Conscios , Alert
• Average Built
• Pallor- Not present
• Icterus - Not Present
• Cyanosis- Not Present
• No jvp engorgment
• Bilateral Carotids Palpable
• No Palpable Lymphadenopathy
• Thyroid Gland not palpable
• A scar mark is present over the left side of the neck

6. • A soft swelling is present on the left side of the neck below the mandible
extending to the left ear. Further swelling is described under local
examination.
• No Clubbing
• Pulse 92 per minute, regular, normovolumic, normal pressure, no radio-radial
delay or radio-femoral delay, all peripheral pulses palpable, no special
characther present.
• Respiratory rate- 18 per minute , regular.
• Afebrile
• Blood Pressure- 88/59mmHg
• No Pedal edema
• Weight- 11 kg

7. • Local Examination
• Single, non pulsatile, smooth, measuring 6 × 4 cm diameter.
• Skin - non inflamed, non tender.
• Swelling is present in left Submandibular region extending from
midline to the angle of mandible.
• Swelling was soft and compressible.
• No relationship with deglutition and coughing.
• Translucency test positive.

8. Systemic Examination
• Cardiovascular System
• Inspection shape of precordium normal.
• Palpation apex is present mid clavicular region on 4th intercostal
space.
• Auscultation normal S1 S2 present.

9. • Respiratory System
• Inspection shape is normal ,
• Palpation trachea is midline,
• Movement - Both side of chest are equally moving with respiration.
• Resonant note on both side of chest,
• Auscultation normal vesicular breath sounds present.

10. • Abdominal Examination
• Soft
• No palpable organomegaly present .
• Genitals not examined.

11. • CNS
• Conscious oriented and alert.
• Milestones with in normal limit.
• All cranial nerves intact.
• Superficial and deep reflexes normal.

12. Airway examination
• Mouth opening adequate
• MP grade cannot assed
• Neck movement normal
• No loose teeth
• Tongue was elevated
• Floor of mouth elevated

13. INVESTIGATIONS
Complete Blood Count
Hb- 13gm%
TLC- 5420
Platelets- 3.8 lakhs
LFT-
Bilirubin Total- 0.5 mg/dl
Bilirubin Direct- 0.2 mg/dl
Bilirubin Indirect- 0.3 mg/dl
SGOT- 26IU/L
SGPT- 10IU/L
ALP- 206 U/L

14. • Renal Function Test-
• Urea - 26 mg/dl
• Creatinine- 0.51 mg/dl
• Na+- 137 mEq/L
• K+- 4.26 mEq/L
• Cl- - 97mEq/L
• Coagulation Profile -
Prothrombin time-
• Test- 16
• Control- 14
• INR- 1.1

15. Differential Diagnosis
• Congenital- Thyroglossal cyst
Branchial Cyst
Sternocleidomastoid Tumour
• Thyroid Swelling- Nodule, Ectopic Tissue
• Salivary Gland swelling
• Lymph node Swelling
• Abscess
• Lipoma

16. • Chest x ray Normal
• USG & MRI - Suggestive of Cystic swelling Hygroma.
• Hence Surgery was planned for excision of the swelling.

17. Anesthetic Consideration
• Consent for Anaesthesia and Surgery taken from the parents.
• Patient taken under ASA grade 1.
• NPO for 2 hours for clear fluids.
• No Pre medication was given.
• Patient shifted to theatre.

18. • Patient was covered with cotton roll and warm blanket.
• All monitoring devices attached –
• Pulse Oximeter,
• Heart rate,
• Temperature,
• ECG,
• Blood Pressure.

19. • Preoxygenation and Induction
• Patient was given 100% O2 via Jackson Rees circuit.
• Difficult intubation cart and fibreoptic was ready.
• Induction agent - Sevoflurane.

20. • After the patient become asleep
• IV line secured with 24 G cannula in left hand.
• IVF Ringer Lactate (warm) started according Holiday sanger formula.
• Inj Glycopyrrolate 0.005mg/kg
• Inj Midazolam 0.05mg/kg
• Inj Dexamethasone 0.1mg/kg
• Inj Fentanyl 1mcg/kg
• Inj Propofol 1mg/kg
• Relaxed with Inj Succinylcholine 1mg/kg

21. • Sevoflurane stopped.
• Direct laryngoscopy was done using Machentosh Blade no 2.
• Comark Lehnac Grade 2B visualized .
• Non Cuffed ETT of 3.5 was inserted .
• Bilateral air entry checked and fixed.
• Oropharyngeal packing was done.
• Intraoperatively patient was ventilated via Jackson Rees circuit and
end tidal CO2 was attached .

22. • Maintanence of Anesthesia via Sevoflurane + N2O+O2
• Relaxation was given with Inj Atracurium 0.05mg/kg bolus and then
intermittently according to the requirment.
• Intraoperatively Input and output charting and blood loss was also
monitered.

23. • Intraoperatively Inj Paracetamol 20mg/kg IV was given.
• Surgery lasted for 2 hours.
• Inj Ondensetron 0.1mg/kg IV and Inj Hydrocortisone 10mg/kg IV
given 30 min before the end of surgery.
• For postoperative pain diclofenac suppository 1mg/kg was given.
• After surgery all inhalational anesthetic gases were switched off.
• Adequate succtiong done under direct vision.
• Oral pack was removed.

24. • Reversal of neuromuscular blocker was done by Inj Neostigmine
0.05mg/kg with Inj Glycopyrrolate 0.01mg/kg.
• After adequate reversal of neuromuscular strength patient was
extubated in left lateral position.
• Nebulised with Adrenaline (1: 1000) in Theatre.
• Shifted to post operative recovery unit for monitoring.
• Total urine output 30 ml
• Total blood loss 50- 70ml