OROPHARYNGEAL AV MALFORMATION – TRACHEOSTOMY TO THE

RESCUE
INTRODUCTION

Vascular anomalies or malformations are usually present at birth and can increase in size with age.
They can be arterial, venous, lymphatic, or a combination of these. Treatment modalities generally
include sclerotherapy, embolization and surgical. For patients with VM in the tongue, floor of the mouth
or soft palate or parapharyngeal area, the airway may be compromised and prophylactic tracheotomy is
often adviced.Here we report a case of extensive oral and pharyngeal av malformation, extending upto
the neck, for sclerotherapy.

CASE REPORT
A 28 year old male patient presented with history of swelling over lower lip, tongue ,floor of mouth and
neck since childhood , increasing with age and with occasional history of bleeding from the swelling.
On examination patient was vitally stable with mouth opening more than 3 fingers, MPC grade 1.All
routine blood investigations were normal. MRI revealed vascular lesion involving lower jaw, floor of
mouth,epiglottis,oropharynx and nasopharynx with mass effect and significant narrowing of the
oropharynx and nasopharynx suggestive of av malformation.

Patient was planned for sclerotherapy in the DSA procedure room at a later date.Due to anticipated
difficulty in airway , elective tracheostomy was done under local anaesthesia 2 days prior to the
sclerotherapy procedure and a 7.5mm tracheostomy tube was inserted and left in situ.

On the day of the procedure , after taking informed consent and confirming adequate starvation, patient
was taken inside , 20 gauge iv cannula was taken and all basic monitors were attached. Baseline
saturation on room air was 100%. Patient was given 1 mg midazolam iv . Tracheostomy cuff was inflated
and was connected to the ventilator circuit. Oxygen and nitrous was given in the ration of 50:50 and
sevoflurane was started and a mac of 0.5 was maintained and patient was under spontaneous
ventilation. Fentanyl boluses of 10 mcg was given during the procedure for a total dose of 50 mcg.

The procedure lasted for 45 minutes and was uneventful. After the procedure patient was given 100%
oxygen and tracheostomy cuff was deflated and patient was shifted to recovery where he was observed
for another 30 minutes.

DISCUSSION

Anaesthesia management of such vascular manformations of the airways are quite a challange as they
present with anticipated difficult airway. Any pressure or force during airway instrumentation can
cause rupture and bleeding of the malformation, with a serious threat of aspiration.In our patient we
anticipated difficult mask ventilation and intubation as well as insertion of supraglottic airway owing to
extensive upper airway involvement of the AV malformation. Hence the decision for elective
tracheostomy well in advance of the procedure.The goals of anaesthesia in this case are protection of
the airway, maintaining adequate depth of anaesthesia, and sustaining patient immobility during the
procedure.
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Arteriovenous Malformation of Face: A Challenge to Anesthesiologists
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