A 40-year-old male presented with fever and cough of two weeks duration which did not settle with conservative management. CT chest revealed benign appearing large mediastinal non enhancing cyst of 7 x 8 x 9 cm causing pressure effect over the adjacent mediastinal vascular structures, esophagus, left bronchus and extending below and above aortic arch and occupying space between superior vena cava and ascending aorta.
As a precaution, left femoral artery and vein was exposed and looped under local anesthesia. Airway was secured and lung isolation was achieved with double lumen tube under inhalation anesthesia. The patient underwent complete removal of posterior mediastinal tumor through left posterolateral thoracotomy in right lateral position. Complete excision of the mass was achieved without any damage to the surrounding structures. Lymph node masses were also removed. Patient had an uneventful postoperative recovery.
This case highlights some of the difficulties associated with the management of large mediastinal mass. Though rare, they cause compression of vital structures causing respiratory insufficiency or hemodynamic compromise. Detailed preoperative evaluation and planning is required to ensure a successful outcome. We were prepared to go on emergency cardiopulmonary bypass in case there was a loss of airway or hemodynamic collapse at induction. Additionally, postoperative evaluation of airway for bronchomalacia was done on spontaneous breathing prior to extubation.