Abstract
A case of left cerebellopontine angle acoustic nerve schwannoma in sitting position with electromyographic(EMG) monitoring for facial nerve was managed. The 40 year old male, ASA II, presented with complaints of difficulty in walking, left sided hearing loss, diminution of vision since 3 years and Magnetic Resonance Image (MRI)suggestive of left CPA acoustic nerve schwannoma. Patient was operated under general anaesthesia in sitting position with Mayfield clamp on head without using muscle relaxant as the plan was to use EMG monitoring during tumor resection. Anesthesia was maintained with sevoflurane and propofol and no muscle relaxant was used, yet patient was immobile. Throughout the procedure haemodynamic stability was maintained with noradrenaline injection. Procedure was uneventful with complete excision of tumor and without damaging the facial nerve. Excision of this deep-seated tumor in sitting position without using muscle relaxant is very difficult to manage. This surgery was very challenging from anaesthetic point of view as sitting position itself increases the risk of complications and avoiding movement of patient with Mayfield clamp without using muscle relaxant was a tough job.
Highlights
The sitting position was introduced in clinical practice by De Marte in 1973 [1]
Usage of intraoperative EMG monitoring will definitely reduce the risk of damaging facial nerve, but becomes more challenging for an anaesthetist to maintain motionless patient in sitting position with Mayfield clamp on head of the patient
Vestibular schwannoma accounts for 75 to 85% of all cerebellopontine angle (CPA) tumors; Schwannomas are the primary lesion of cranial nerves involving trigeminal, facial, glossopharyngeal, vagus and sometimes even accessory cranial nerve [7]
Summary
The sitting position was introduced in clinical practice by De Marte in 1973 [1]. it has been declining in popularity since the 1980s due to high incidence of complications. Sitting position has been used for resection of tumors in cerebellopontine angle, pineal region, other technically difficult tumors in infratentorial region as well as surgeries of cervical spine. The advantages of this position is that it provides drainage of CSF and blood, provides easy access to airway and promotes favorable changes in ventilatory mechanics. This position has several life threatening complications such as venous air embolism, postural cardiovascular effects because of general anesthesia, macroglossia, pneumocephalous, quadriplegia and peripheral nerve injury [2].
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