Anesthesia in a patient with nasopharyngeal angiofibroma and hemophilia A

LETTERS TO THE EDITOR

Anesthesia in a Patient With Nasopharyngeal Angiofibroma and Hemophilia A To the Editor: We read with great interest the article entitled “Anesthetic Management of Juvenile Nasopharyngeal Angiofibroma Resection” by Ezri et al.1 We wanted to share our similar experience in a patient with hemophilia A and a nasopharyngeal angiofibroma. Nasopharyngeal angiofibroma is a rare benign fibrovascular tumor that can lead to severe, life-threatening epistaxis. We present the anesthetic approach to the nasopharyngeal angiofibroma in a patient with hemophilia A. A 17-year-old male patient who had hemophilia A and a nasopharyngeal mass occluding the cavity had undergone a biopsy in another medical center. After the biopsy, he had life-threatening severe hemorrhage, and tracheotomy had been performed to avoid the risk of aspiration. Histopathologic results revealed a nasopharyngeal angiofibroma. The patient was admitted to our hospital with this diagnosis. To provide for less blood loss throughout the operation, embolization was performed on the tumor mass. Factor VIII was given at 2-hour intervals to keep his serum factor VIII levels at 100% during surgery. He was premedicated with oral diazepam because intramuscular injections may lead to unexpected hematoma. Anesthesia was induced with propofol and vecuronium and maintained by isoflurane and 30% N2O in oxygen. He was intubated through the stoma of the tracheotomy with a cuffed endotracheal tube. Electrocardiogram, invasive arterial blood and central venous pressures, pulse oximetry, capnography, and urinary output measurements were recorded. Two 14-G intravenous catheters were placed in the upper extremities. Also, right internal jugular vein was cannulated with a 14-G catheter. Mean arterial pressure was 55 to 75 mmHg throughout the surgery. This was maintained with increasing concentrations of isoflurane and fentanyl, 5 ␮g/kg, when required. During the procedure, which lasted 4 hours, 3,000 mL of crystalloid, 1,000 mL of colloid, 4 units of erythrocytes, and 4 units of plasma were given. Total urinary output and blood loss were 800 mL and 2,000 mL, respectively. The hemoglobin level was maintained around 10 g/dL. Platelets were given in addition to packed cells. Body temperature was preserved by warming the fluids and blood, and warming blankets were used. Intraoperative hypotension and metabolic acidosis were not detected. He was extubated at the end of the surgery and transferred to the intensive care unit. He was discharged from the hospital without any complication. The anesthetic approach during surgery for juvenile nasopharyngeal angiofibroma resection is important in 3 respects: (1) risk of blood aspiration during induction of anesthesia, (2) major surgical bleeding, and (3) airway obstruction after extubation because of edema related to surgery. Since the patient had a tracheotomy, airway management did not lead to any difficulty. Massive blood loss is expected to be a major concern during resection of juvenile nasopharyngeal angiofibroma, especially in a patient with hemophilia A.2 Similar to Ezri et al,1 we used isoflurane and fentanyl for deliberate hypotension. Appropriate preoperative precautions and induced hypotension during surgical resection of nasopharyngeal angiofibroma in a patient with hemophilia A provided a safe and successful outcome. Varol Celiker, MD Elif Basgul, MD A. Heves Karagoz, MD Didem Dal, MD Department of Anesthesiology and Reanimation Hacettepe University Ankara, Turkey REFERENCES 1. Ezri T, Roth Y, Geva D, et al: Anesthetic management of juvenile nasopharyngeal angiofibroma resection. J Cardiothorac Vasc Anesth 17:622-624, 2003 2. Ozturk MA, Haznedaroglu IC, Ozturk MH, et al: Nasopharyngeal angiofibroma in a patient with haemophilia A: A bleeding tumour in a bleeding-prone patient. Haemophilia 5:207-208, 1999 doi:10.1053/j.jvca.2004.08.030

Journal of Cardiothoracic and Vascular Anesthesia, Vol 18, No 6 (December), 2004: pp 819-826

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