Anaesthetic management of a huge mediastinal tumour with tracheobronchial compression

A 20 year old man diagnosed to have multiple neurofibromatosis presented with 2 months history of orthopnoea and cough with moderate expectoration since 1 month. Chest Xray and CT scan showed a huge mediastinal mass with compression of the trachea and superior vena cava. In view of the anticipated airway problems, an awake intubation in the sitting position was achieved. Cardiopulmonary bypass was not considered because of the possibility of excessive bleeding after heparinization. Despite this, the patient bled about 4,500 mL. Tracheomalacia was suspected intraoperatively. A larger endotracheal tube was inserted at the end of the procedure and the patient ventilated electively overnight. He was successfully extubated 24 hours later.