Asploro Journal of Biomedical and Clinical Case Reports

Asploro Journal of Biomedical and Clinical Case Reports

Xiao Bai^1*
1Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China

Corresponding Author: Xiao Bai
Address: Department of Anesthesiology, West China Hospital, Sichuan University, No. 37, Guoxue Valley, Wuhou District, Chengdu, Sichuan 610041, China.
Received date: 11 August 2025; Accepted date: 16 August 2025; Published date: 20 August 2025

Citation: Bai X. Anesthesia Induction and Reflections for a Giant Floor of Mouth Mass in an Infant: A Case Report. Asp Biomed Clin Case Rep. 2025 Aug 20;8(3):248-49.

Copyright © 2025 Bai X. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium provided the original work is properly cited.

Keywords: Anesthesia Induction, Giant Floor of Mouth Mass, Pediatric Difficult Airway, Kaposi Sarcoma in Infants, Airway Management Strategy

Abstract

Infants possess unique anatomical and physiological characteristics that increase the risk of severe hypoxemia during airway management. A floor of mouth mass causing tongue displacement may directly induce airway obstruction, further elevating anesthetic risks. This report details the anesthesia induction strategy for a 3-month-old infant with a giant floor of mouth mass, discussing safe airway establishment in pediatric difficult airways.

Introduction

Infants exhibit distinct anatomical features: a large head with prominent occiput promotes cervical flexion in the supine position, misaligning the oropharyngeal axis; a proportionally large tongue and hypertrophic glands reduce intraoral space; a longer epiglottis complicates direct laryngoscopy; and a high larynx with short, narrow trachea means mild edema significantly increases airway resistance. Physiologically, low functional residual capacity combined with high oxygen consumption accelerates desaturation. Head/neck hemangiomas, as independent risk factors [1], compound these challenges [2,3]. In cases of difficult airway management in neonates and young children, the mortality rate is 30–40% of all deaths related to anesthesia practice.

Case Report

A 3-month-old male (55 cm, 4.8 kg) presented with a progressive pink spherical mass in the floor of mouth and four pea-sized mandibular red patches noted at birth. The mass caused intermittent dyspnea. An incisional biopsy was planned for pathological diagnosis. Physical examination revealed significant tongue elevation, intercostal retractions during quiet breathing, and normal swallowing. MRI demonstrated a 7×4 cm mass involving bilateral submandibular and submental regions. Given the mass size and anticipated difficulty in establishing an emergent surgical airway if biopsy caused hemorrhage, tracheal intubation was planned with ENT backup. Equipment included a video laryngoscope, 2.2 mm bronchoscope, laryngeal mask, and 3.0 mm endotracheal tube.

After shoulder roll positioning for mild head extension, inhalational induction was initiated with 2% sevoflurane and 4 L/min oxygen. Spontaneous ventilation was maintained (tidal volume ≈30 ml, respiratory rate ≈35/min), with jaw thrust resolving retractions. After 10 minutes, intravenous dexamethasone (1 mg) and succinylcholine (5 mg) were administered. Video laryngoscopy achieved Grade I glottic view, allowing uneventful insertion of a 3.0 mm ETT to 10 cm depth. Bilateral breath sounds and ETCO₂ (35 mmHg) confirmed placement.

Under ultrasound guidance, two submental biopsies were obtained. Post-biopsy compression for 5 minutes and ultrasound verification of no hematoma preceded transfer to the ICU with ventilator support. The infant was extubated 3 hours postoperatively following stable spontaneous breathing and absence of neck swelling. Pathology confirmed Kaposi sarcoma, prompting sirolimus therapy. The patient returned to the general ward on postoperative day 3.

Discussion

This case involved an anatomically difficult airway where biopsy-related hematoma risk favored tracheal intubation over supraglottic devices or spontaneous ventilation. Slow sevoflurane induction preserved spontaneous respiration [3], avoiding positive-pressure exacerbation of obstruction. Although tongue displacement suggested potential laryngoscopy difficulty, Grade I view was achieved. Postoperative ICU ventilation mitigated edema risk despite smooth induction. Real-time ultrasound surveillance ruled out hematoma, enabling early extubation [3].

Key Considerations

1. Pre-induction positioning (shoulder roll) optimizes airway alignment.
2. Spontaneous ventilation induction minimizes mass compression risks.
3. Multidisciplinary preparedness (ENT) is non-negotiable for giant masses.
4. Ultrasound provides critical dynamic assessment for early extubation decisions.

Conflict of Interest

The author has read and approved the final version of the manuscript. The author declares no conflicts of interest.

References

[1] Krishna SG, Bryant JF, Tobias JD. Management of the Difficult Airway in the Pediatric Patient. J Pediatr Intensive Care. 2018 Sep;7(3):115-25. [PMID: 31073483]

[2] Kane T, Tingay DG, Pellicano A, Sabato S. The neonatal airway. Semin Fetal Neonatal Med. 2023 Oct;28(5):101483. [PMID: 38030433]

[3] Zimmermann L, Maiellare F, Veyckemans F, Fuchs A, Scquizzato T, Riva T, Disma N. Airway management in pediatrics: improving safety. J Anesth. 2025 Feb;39(1):123-33. [PMID: 39556153]