Respiratory Distress and Mediastinal Mass

Children with a mediastinal mass and respiratory distress present a difficult therapeutic and diagnostic dilemma. These children often complain of cough, difficulty breathing, stridor, and shortness of breath. They prefer to sit upright and cannot tolerate supine positioning. The chest radiograph usually shows a large mediastinal mass, often with obliteration or obscuring of the tracheal air column. These tumors can be either malignant (87% Hodgkin's and non-Hodgkin's lymphoma) or benign; the prognosis and therapy rely on an adequate diagnosis. The diagnosis is best made by tissue sampling before any therapy.^[330] However, a problem may result because tissue sampling of a mediastinal mass requires anesthesia and surgery; by necessity, the airway must be manipulated and instrumented.

The obstructed intrathoracic trachea presents a major anesthetic risk; it is often impossible to maintain such an airway with the patient supine, deeply anesthetized, or receiving muscle relaxants.^[331] Care of these patients clearly requires individualized and creative approaches. If the airway compromise is severe, blind tumor therapy at the expense of obscuring the tissue diagnosis must precede any diagnostic procedure. Mediastinal irradiation and systemic steroids are the two modes of emergency therapy most commonly administered. Sometimes, this diagnostic dilemma can be circumvented; peripheral nodes or masses can undergo biopsy under local anesthesia, or if the tumor mass is very large, some of the tumor may remain outside the radiation field. In summary, although diagnosis is the key to neoplastic disease, a mediastinal mass is one situation in which the risk may far outweigh the benefit of tissue diagnosis.

Fever and Neutropenia

The most common admission diagnoses for children with neoplastic disease are fever and neutropenia. The neutropenic immunocompromised state caused by chemotherapy is a high-risk period for life-threatening infections.