Case Report: Awake double-lumen tube intubation and intraoperative ventilation strategy conversion in an obese adolescent with a giant anterior mediastinal teratoma.

BACKGROUND

Anterior mediastinal masses may precipitate life-threatening airway or cardiovascular collapse during anesthesia. In obese adolescents, symptom-based assessment may underestimate the risk when substantial airway compression and pericardial effusion are present.

CASE PRESENTATION: A 13-year-old boy with class II obesity (body mass index [BMI] 36.0 kg/m2) presented with a 10.4 × 9.7 cm anterior mediastinal mass compressing both the trachea and the left main bronchus, accompanied by a moderate-to-large pericardial effusion. Despite minimal respiratory symptoms, imaging findings supported a high-risk classification. Awake oral intubation using a 37 Fr left double-lumen tube (DLT) was performed without sedation under multilevel topical anesthesia while spontaneous ventilation was maintained. Fiberoptic bronchoscopy revealed a slit-like left main bronchial orifice, and the bronchial tip could not be advanced safely. The DLT was withdrawn into the main airway, and both lumens were used for bilateral ventilation. Transient permissive hypercapnia occurred (PaCO₂ 52.7 mmHg, pH 7.289) with preserved oxygenation, and PaCO₂ improved after thoracotomy without changes in ventilator settings. The tumor was completely resected, and pathology confirmed a mature teratoma.

CONCLUSION

This case illustrates a practical airway-first strategy for managing a high-risk adolescent with an anterior mediastinal mass and suggests that, in selected patients with an already secured main airway, temporary bilateral ventilation through both DLT lumens may serve as a feasible rescue option when bronchial positioning fails.