Giant lip hemangioma is a rare disease that may cause difficulty in preoxygenation and ventilation when using face masks and intubation during general anesthesia induction.
A laparoscopic cholecystectomy was planned for a 77-year-old woman. The patient had a giant lower lip hemangioma that was 12 x 5 x 5 cm, which made preoxygenation and ventilation through a face mask impossible and put her at risk of hemangioma rupture. We preoxygenated her through a high-flow nasal cannula (HFNC). Following propofol and succinylcholine administration, we intubated the patient with a video laryngoscope without desaturation, hemangioma rupture, or CO2 retention.
HFNC is a useful tool when difficult intubation is expected in patients who have problems using conventional face masks.
Hemangioma is the most common benign tumor of vascular origin. Hemangiomas located around the airway can significantly increase the difficulty of endotracheal intubation as they occupy space and might rupture [
High-flow nasal cannula (HFNC) supplies a high flow of warm, humidified air or oxygen to the nasopharynx, reducing re-breathing and dead space, which in turn reduces CO2 retention [
We report on a patient with giant lower lip hemangioma who was expected to have a difficult airway and who seemed to be impossible to preoxygenate and ventilate with a face mask. We successfully preoxygenated the patient through HFNC to induce anesthesia without desaturation.
A 77-year-old female patient who was 153 cm tall and weighed 58 kg was admitted to hospital with chronic diarrhea. Abdominal and pelvis computed tomography showed that she had cholangitis due to gallbladder stones. The patient had a congenital giant hemangioma of the lower lip (
Laparoscopic cholecystectomy was planned. Due to the giant hemangioma of the lower lip, airway management was expected to be difficult because it seemed like a mask would not fit. The hemangioma was 12 × 5 × 5 cm (
A hemangioma is a malformation of vascular structures that is at risk of rupture. Its incidence rate is higher in females, Caucasians, premature infants, twins, and infants born from elderly mothers. The most common site is the head and neck region (60%) and followed by the trunk (25%) and limbs (15%). Of these, hemangiomas occurring in the lip area are classified as either superficial, deep, or mixed according to their depth. The patient in this case had a mixed type, which accounts for 49% of hemangiomas. Among lip hemangiomas, 60% occur in the upper lip, 36% in the lower lip, and 6% were in commissure form [
In this case, we used HFNC to preoxygenate and avoid hypoxia and intubated the patient using a video laryngoscope. The lesion was on the lower lip and it was large, so a mask would not fit, limiting the use of airway maintenance devices, including oropharyngeal airways. Without an airway-securing device, patients are prone to be hypoxic during anesthesia induction. There were also high risks of bleeding and aspiration if the hemangioma was damaged during airway manipulation. Bleeding may have hindered the clear visualization of anatomical structures, making intubation even more challenging [
HFNC has many advantages over conventional oxygenation devices. HFNC supplies high oxygen flow and can warm and humidify it regardless of the high flow. Humidification enhances the washout of secretion and avoids mucosal injury. A high flow of oxygen reduces dead space because it decreases re-breathing and it generates positive end-expiratory pressure, which is higher with the mouth closed and is proportional to the flow. HFNC washes out CO2 during apneic oxygenation [
However, the use of HFNC is not well established in any difficult airway guidelines. Studies comparing HFNC with conventional devices are ongoing. It may be suitable for use for ventilation in a patient with severe hypoxemic respiratory failure, preoxygenation during general anesthesia, intubation support, post-extubation support, oxygenation during bronchoscopy in a patient with a high risk of respiratory decompensation, and ventilation in laryngologic surgery [
There is controversy about whether HFNC can be used as a preoxygenation and ventilation device as an alternative to conventional face masks to induce general anesthesia. Studies show that apneic oxygenation through HFNC has a longer apnea time than apneic oxygenation through a face mask [
We searched and reviewed cases in which face mask ventilation was not possible due to facial lesions and alternative methods were used. Full-text reviews were conducted for six articles [
In conclusion, we successfully managed a giant lower lip hemangioma patient for whom preoxygenation through a face mask seemed ineffective and bag-mask ventilation seemed difficult using HFNC. HFNC can be useful when difficult intubation is expected in patients who would have difficulty using a conventional face mask.
None.
No potential conflict of interest relevant to this article was reported.
Ji Yeon Kim (Supervision; Writing – original draft)
Hangaram Kim (Writing – original draft)
Min Hee Heo (Writing – review & editing)
Kyung Woo Kim (Writing – review & editing)
Sang-Il Lee (Writing – review & editing)
Kyung-Tae Kim (Writing – review & editing)
Jang Su Park (Writing – review & editing)
Won Joo Choe (Writing – review & editing)
Jun Hyun Kim (Conceptualization; Supervision; Writing – review & editing)
The giant hemangioma of the lower lip, mixed type.
Size measurement of lower lip giant hemangioma.
Preoxygenation with HFNC in giant hemangioma patient. HFNC: high flow nasal cannula.
Cases Using Alternative Preoxygenation Devices due to Difficult Face Masks Fitting
Authors | Age (yr)/Sex | Type of lesion | Preoxygenation method | Intubation method | Mallampati/Comack-Lehan | Size of lesion |
---|---|---|---|---|---|---|
Neeta et al. [ |
65/F | AVM of nose | SAD (i-gel) | Direct laryngoscopy | 2/N/A | 7 × 7 cm |
Asai et al. [ |
53/F | Post gangrenous mass | SAD (Fastrach) | Awake FOI through SAD | N/A/N/A | 5 × 5 cm |
Nafiu and Coker [ |
17/M | Intraoral mass | SAD (N/A) | SAD in situ | N/A/N/A | N/A |
Saini and Bansal [ |
1/M | Cystic hygroma | SAD (Proseal) | Direct laryngoscopy | N/A/N/A | 12 × 10 cm |
Saini et al. [ |
28/F | Neurofibroma | Rendell-Baker-Soucek | Direct laryngoscopy | N/A/N/A | N/A |
Gusti et al. [ |
68/M | Rhinophyma | HFNC | Videolaryngosopy | 2/1 | 12 × 7 cm |
AVM: arteriovenous malformation, FOI: fiberoptic intubation, HFNC: high flow nasal cannula, N/A: not available, SAD: supraglottic airway device.
PUBMED, EMBASE
(‘difficult face mask’ or ‘difficult face mask’ or ‘difficult face mask’ or ‘difficult mask’ or ‘difficult airway’ or ‘impossible mask’ or ‘lip hemangioma’ or ‘face tumor’ or ‘face lesion’ or ‘perioral lesion’ or ‘perioral tumor’ or ‘face malformation’ or ‘circumoral tumor’ or ‘face deformity’) and (‘preoxygenation’ or ‘alternative airway’ or ‘laryngeal mask’ or ‘laryngeal airway’ or ‘HFNC’ or ‘High flow nasal cannula’ or ‘THRIVE’ or ‘transnasal humidified rapid insufflation ventilatory exchange’ or ‘rendell baker’ or ‘oxygen hood’ or ‘oxygen tent’ or ‘venturi mask’ or ‘non rebreather’ or ‘non rebreathing’)