From the Department of Pediatric Surgery and
Pediatrics, Post Graduate Institute of Medical Education and Research,
Chandigarh, India.
Correspondence to: Dr. K.L.N. Rao, Professor and
Head, Department of Pediatric Surgery, P.G.I.M.E.R., Chandigarh 160
012, India. E-mail:
klnrao@hotmail.com
Manuscript received: November 21, 2002; Initial review completed:
January 17, 2003; Revision accepted: February 28, 2003.
Abstract:
We report a 5-month-old boy who presented with
an anterior mediastinal cystic teratoma. Pre-operative symptoms of
respiratory distress secondary to airway obstruction were markedly
reduced by percutaneous aspiration. Aspiration was also beneficial
in easily ventilating the baby during the surgical procedure.
Key words: Mediastinal teratoma, Percutaneous
aspiration.
Large mediastinal cysts can present with severe
respiratory distress in infancy. Percutaneous guided aspiration is
beneficial in such cases to stabilize the patient before surgical
intervention. We report the benefits of such an intervention in an
infant with an anterior mediastinal cyst.
Case Report
A 5-month-old boy was admitted with complaints of
breathlessness and dry cough of 2.5 months duration, with recent
exacerbation of symptoms. There was no history of fever or
hemoptysis. There was one episode of cyanosis. There was history of
vomiting and difficulty in feeding. On examination, there was
pallor, tachypnea, suprasternal and bilateral subcostal recession.
Trachea was in the midline. Air entry was equal on both sides. The
plain X-ray chest showed a large soft tissue shadow occupying almost
the entire upper one-third of the thorax (Fig. 1). The hematological
and biochemical parameters were within normal limits. Computed
tomography (CT) of the chest showed a cystic lesion occupying the
anterior and superior mediastinum (Fig. 2). In view of the
respiratory distress and the cystic nature of the swelling,
aspiration was performed through the 2nd intercostal space on both
sides. About 60 mL of clear fluid was easily withdrawn. This
dramatically reduced the symptoms of the patient. A repeat chest
X-ray showed a marked decrease in the size of the swelling.
Biochemical analysis of the fluid showed a protein content of 20
mg%, glucose of 59 mg% and adenosine deaminase (ADA) of 9 IU/L.
Fluid cytology demonstrated clusters of benign columnar epithelial
cells, mature squamous cells, lymphocytes and plasma cells. With his
condition now improved, the child underwent a left anterolateral
thoracotomy.
Fig. I. PA view of the chest radiograph showing a large
anterior
mediastinal mass occupying both halves of the chest.
Fig. 2. CT Scan of the chest showing a large anterior
mediastinal
cyst. Solid component could be seen on the left side of the lesion.
The cyst was aspirated again under vision. This
not only improved his ventilation but also helped in easy excision
of the cyst, which was extending to the opposite side of the chest.
Major blood vessels, airways as well as the left phrenic and
recurrent laryngeal nerve were identified and protected during
surgery. He had an uneventful post-operative course and at 5-month
follow-up is asymptomatic. The histopathological report showed an
immature teratoma.
Discussion
Approximately 8% of all mediastinal tumors are
benign teratomas, the majority being located anteriorly(1). The
tumors are usually partially cystic(2). The primary cystic and
neoplastic lesions of the anterosuperior mediastinum include
thymomas (30%), lymphomas (20%), germ cell tumors (18%) and
carcinomas (13%)(3). Patients with benign teratomas are usually
young adults and about 36% are asymptomatic(2).
Symptoms pertaining to airway obstruction in
mediastinal masses may be present pre- operatively or may develop
during induction of anesthesia. The latter may be sudden and life,
threatening(4,5). The effect of anesthesia on pulmonary mechanics,
the supine body position and the elimination of glottic regulation
of airflow by endotracheal intuba-tion have all been postulated as
causes of exacerbation of compression of major airways during
induction(4). Transcarinal aspiration of a mediastinal cyst
following marked inter-ference with gas exchange after institution
of general anesthetic has been reported in this context(6).
The therapeutic use of transbronchial needle
aspiration for a bronchogenic cyst has been reported, although,
there was exudative effusion after this procedure(7). Percutaneous
aspiration of pericardial cysts without further recurrence has been
reported(8). Ethanol sclerosis has also been used in the management
of pericardial and thymic cysts(9). Mediastinal cyst aspiration has
been attempted during thoracoscopic resection and was found to avoid
spillage as well as allow better manipulation and easier grasping of
the cyst(10). This benefit was noted in our patient also, wherein
the entire lesion including the part extending to the opposite side
could be excised easily through a left thoracotomy approach alone.
Following aspiration, cyst fluid can rapidly
re-accumulate. Aspiration cytology alone does not always give the
exact pathology of the lesion and a malignancy may be missed.
Therefore, aspiration as the only modality of treatment is not
recommended. Complete surgical excision continues to be the
treatment of choice.
There is no previous case report of percutaneous
guided aspiration for alleviating symptoms of respiratory tract
obstruction in cystic lesions of the anterosuperior media-stinum in
young children. Perioperative symptoms and complications were
reduced by aspiration prior to surgery in our patient. We therefore
recommend preoperative guided aspiration in large symptomatic cystic
lesions of the mediastinum to alleviate patient symptoms and reduce
anesthetic risks.
Acknowledgement
Authors thank Prof. A. Rajwanshi and Prof. R.K.
Marwaha for their active role in patient management.
Contributors: PM performed drafting of
manuscript, literature search and contributed to patient management.
AT investigated the patient. KLNR finally approved the manuscript
and will act as guarantor for the manuscript.
Funding: None.
Competing interest : None stated.
