Case report
A 9 years old male child presented with complaints of rapidly progressive shortness of breath for the last 2 months more on supine position. The patient had a history of progressively increasing swellings in upper limbs, lower limbs, and chest wall since the age of 2 years. The patient had a large, irregular, bony-hard, swelling involving Upper 2/3 of sternum, suprasternal notch and right shoulder. [fig.1]. The bony mass over suprasternal notch was compressing the cervical part of the trachea, causing stridor. The swellings of extremities were of cosmetic concerns only. The father of the patient also had bony swellings over the right humerus and left femoral bone. Computed tomography (CT) of the thorax showed a large exophytic bony mass involving sternum and right side of chest wall [Fig 2A, 2B, 2C, 3A, and 3B]. The mass was encroaching in suprasternal notch causing compression of the trachea at the level of lower border of C7 vertebra. The minimum anteroposterior diameter of the trachea was 3.4 mm [Fig. 2D]. Multiple other bony exostoses also have seen arising from ribs [Fig 2C] and scapula.
The key challenge in this patient was the severe external compression of the trachea, not permitting the minimum required size of the endotracheal tube. The case was discussed by the multidisciplinary team. Considering the above circumstances, it was decided to perform femoro-femoral Cardiopulmonary Bypass (CPB) under local anesthesia preceding the induction of general anesthesia (GA). Various invasive lines were placed under local anesthesia (LA) for intraoperative monitoring after verbally explaining to the patient. The right femoral artery and vein were exposed under LA and were canulated with 16 and 20 Fr sized canula (Edwards FemFlex®) respectively. Cardiopulmonary bypass (CPB) was established at 80% flow. After that Anaesthesiologists induced the patient and put Flexo-metallic endotracheal tube (ET tube) 4 mm size using a fiber-optic laryngoscope and later, it was exchanged with 5.5 mm using a tube-exchanger. After confirmation of good ventilation via the ET tube, CPB was weaned. The total CPB time was 85 minutes.
A ’T’ shaped incision was given over swelling with transverse limb at the level of the thyroid cartilage and the vertical limb extending up to xiphisternum. The  bony-mass was removed in piecemeal by using chisel, hammer, and oscillating saw while taking care of major neck vessels and trachea. While the suprasternal extension of mass was completely removed, only debulking of sternal body and chest wall mass were done to achieve fair cosmetics result. No evidence of tracheomalacia was found. In view of uneventful post-operative recovery, and absence of any residual respiratory difficulty, the patient was discharged on the fourth postoperative day. Histopathology report was suggestive of Osteochondroma. CT thorax done at one-month follow-up showed an adequate debulking of mass [Fig 3C, 3D] with the normal trachea. The patient was asymptomatic and aesthetically satisfied after 1 year.