Vol 10 | Issue 3 | September-December 2024 | Page: 11-13 | Meera J. Pandey, Vrushali S. Malegaonkar, Namita N. Davange
DOI: https://doi.org/10.13107/jaccr.2024.v10.i03.252
Open Access License: CC BY-NC 4.0
Copyright Statement: Copyright © 2024; The Author(s).
Submitted: 18/06/2024; Reviewed: 11/07/2024; Accepted: 19/09/2024; Published: 10/12/2024
Author: Meera J. Pandey [1], Vrushali S. Malegaonkar [1], Namita N. Davange [1]
[1] Department of Anaesthesia, SMBT Medical College and IMSRC, Nashik, Maharashtra, India.
Address of Correspondence
Dr. Meera Pandey,
Assistant Professor, Department of Anaesthesia, SMBT Medical College and IMSRC, Nashik, Maharashtra, India.
E-mail: meerapandey8184@gmail.com
Abstract
Phenytoin induced gingival overgrowth is a drug induced type of gum hyperplasia, usually seen in patient’s with epileptic disorder on Phenytoin. It is estimated that about 30 to 50% of patients taking phenytoin develop significant gingival alterations either localised or generalized² within 6 months of therapy. It causes difficulties in swallowing, speech and mastication, delayed dentition and recurrent infections. Delayed milestones, paediatric age group and fragile gingival tissue all pose challenge to anaesthesiologist. We report successful management of a child posted for gingivectomy under general anaesthesia.
Keywords: Phenytoin Induced Gum Overgrowth (PIGO), Gingival overgrowth, Videolaryngoscope, Difficult airway, Paediatric age group
Introduction
Several causes of gingival hyperplasia are known, and the most recognized is drug-induced gingival enlargement. Phenytoin is one of the first line drug used for the treatment of epilepsy. Phenytoin induced gum hyperplasia is a known and serious complication seen in patients with seizure disorder. About 30-50% patients on Phenytoin develop gum hyperplasia. The overgrowth takes 2–3 months to become noticeable and can take 12–18 months to reach its maximal severity [3]. PIGO (Phenytoin induced gum hyperplasia) seems to be more prevalent in children and teenagers, but there is no difference on its incidence in regard to gender or ethnic groups [3]. Such patients rarely present in operation theatre for gum excision as most cases are done under Local anaesthesia in OPD (outpatient department) [1]. Cases requiring General Anaesthesia are generally paediatric patient with cerebral palsy or mental retardation who are uncooperative and high risk. These patients are at increased risk for anaesthesia as they have difficult airway, physiological challenges due to paediatric age group and risk of aspiration as gingival growth is fragile and bleeds at slightest of trauma [1].
Case Report:
We report a case of 6-year-old 16.65 kg male child posted for gingivectomy for PIGO (Phenytoin Induced Gum Hyperplasia). The child was born out of non- consanguineous marriage at home birth setting full term normal delivery; did not cry at birth leading to cerebral palsy and mental retardation. The child had delayed developmental milestones and slurring of speech. Vaccination was up to date as per his age. Patient had difficulty in chewing, was eating only semisolid foods and therefore was malnourished. He also had occasional bleeding from gums. Patient was a known case of seizure disorder since 5 years and was taking phenytoin since 2 years. Before that he was on some medication, but as seizures were not controlled he was shifted to phenytoin. He had a MRI done at the age of 3 years but reports were not available. Patient had shunt surgery for hydrocephalus at the age of 3.5 years but no reports available. No other relevant past medical or surgical history. All routine blood investigation were within normal limit. On general examination patient was found to be malnourished. On oral examination gingival overgrowth involving upper teeth from incisors to pre molar was seen. Systemic examination was normal. On auscultation bilateral air entry was equal and heart sounds were normal. Mouth opening was 1.5 fingers, mallampatti grade (MPG) grade 3. Neurophysician opinion was done for cerebral palsy status with mental retardation and no other changes in treatment was advised. Paediatric consultation was done for any other congenital anomalies but were none. Patient was kept NBM (nil by mouth) for 6 hours before surgery.
On the day of surgery patient was shifted to operation theatre. Monitors according to ASA (American society of Anaesthesia) guidelines were attached. Lactated ringers solution was started, through 22G no intracath. Inj. Midazolam 0.8 mg as premedication was given intravenous. Induction was done using inj. Fentanyl 16 mcg (1mcg/kg), inj. propofol 35 mg (2 mg/kg) and inj. Succinylcholine 25 mg (1.5 mg/kg) was done. Video laryngoscopy using MAC 2 blade was done protecting gums with gauze piece. Patient was intubated with 5 no cuffed endotracheal tube fixed at 15 cm after confirming bilateral air entry and End tidal CO2 graph.
Anaesthesia was maintained with controlled ventilation using Oxygen, air and sevoflurane, muscle relaxant used was Inj. atracurium 1.5 mg (0.1 mg/kg). 20 mcg inj. fentanyl was given intermittently in divided doses for analgesia. Intraoperative period was uneventful. Inj. Ondansetron 0.8 mg and inj. Paracetamol 250 mg was given. Sevoflurane was stopped at the end of surgery and switched to100% oxygen. Inj. Neostigmine 800 mcg + inj. glycopyrrolate 160 mcg was used for reversal. Patient was extubated in deep plane, once spontaneous respiration was achieved after thorough oropharyngeal suctioning. Patient was shifted to recovery room and observed for 2 hours.
Discussion:
Seizure disorder are a common occurrence in paediatric patients with cerebral palsy. Phenytoin is most common drug for treatment of the same [4]. Phenytoin induced gum hyperplasia (PIGO) falls under drug induced type of gingival enlargement. It is estimated that 30 to 50% patient developing PIGO occur early within 3 months of use. The side effect takes 2–3 months to become noticeable and can take 12–18 months to reach its maximal severity [3]. It is more prevalent in paediatric age group and young adults [2]. There is no difference in its incidence with regard to gender or ethnic groups [3].
Several mechanisms are involved in development of PIGO [2] (Phenytoin Induced Gum Hyperplasia), main problem being with gingival fibroblasts. Few studies demonstrate that phenytoin inhibits production of extracellular matrix by gingiva fibroblast n cell proliferation. Others show accumulation of protein (collagen) with higher density fibers [2]. Phenytoin decreases calcium cell influx leading to decrease in uptake of folic acid thus limiting production of active collagenase [2]. It also stimulates myofibroblast and causes overgrowth of cytokines IL6, IL1, IL8. It is generally agreed that a dose-PIGO relationship exists in direct proportion [4]. It has been noted that phenytoin must be taken over a sufficient period of time at a sufficient dosage which allows the lesion to initiate [4].
Poor oral hygiene and infection adds to the problem [1]. Most investigators agree on a close relationship between oral hygiene level and degree of gingival over- growth [4]. This overgrowth can be decreased or prevented by good oral hygiene and dental prophylaxis.
General indications for gingivectomy include patients with PIGO (Phenytoin Induced Gum Hyperplasia) affecting aesthetics who appreciate their appearance, affecting by producing an ectopically dentition, occlusal erupting development permanent and affecting mastication to the point of documented weight loss [4]. Depending on severity of the overgrowth these cases are managed. Severe cases requiring gingivectomy are either done in out door patient setting under Local anaesthesia or in operation theatre under general anaesthesia. Indications for inpatient general anaesthesia include non cooperative patients, poorly controlled seizure activity and generalized, severe PIGO (Phenytoin Induced Gum Hyperplasia).
Challenges: 1) Mentally retarded paediatric patients’ uncooperative patients for airway assessment. 2) Difficulty in securing airway. 3) There can be bleeding gums which increases risk of aspiration as these ill formed gums bleed easily even at slightest pressure due to laryngoscopy. 4) Extubation.
Videolaryngoscopy comes handy in such cases [7]. The time duration required is less and learning curve for the procedure is less and success rate is good.
Other options available is awake fiberoptic intubation [5] which needs cooperative patient. It may also require multiple attempts and paediatric patients may desaturate in these scenarios [6].
It is important to remember intubation is an emergency, extubation is never. For cases posted for airway surgery, a nasopharyngeal airway can be inserted to aid deep plane extubation. Also an airway exchange (Aintree catheter) can be inserted in trachea via ET tube if probability of reintubation is high. Suctioning with round tip suctioning catheters are advised to avoid further trauma. Paediatric cases pose a greater risk for laryngospasm during extubation so preparedness for the same is advised.
A thorough preoperative evaluation helps risk stratification in these cases.
Conclusion:
Phenytoin induced gum hyperplasia are rare but challenging case for anaesthetist, but can be very well managed with a thorough preoperative evaluation, gentle video laryngoscopy and thorough intraoperative management.
References
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3. Chacko LN, Abraham S. BMJ Case Rep Published online: Accepted 5 May 2014
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5. C. SEEFELDER* J.H. KO* B.L. PADWA. Fibreoptic intubation for massive gingival hyperplasia in juvenile hyaline ®bromatosis. Departments of *Anesthesia and Oral and Maxillofacial Surgery Children’s Hospital 300 Longwood Avenue Boston.
6. Yasuda A, Miyazawa N, Inoue E, Imai T, Shionoya Y, Nakamura K. Anesthetic Management of a Juvenile Hyaline Fibromatosis Patient With Trismus and Cervical Movement Limitation. Anesth Prog. 2021 Jun 1;68(2):117-118. Doi: 10.2344/anpr-68-01-04. PMID: 34185859; PMCID: PMC8258748.
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| How to Cite this Article: Pandey MJ, Malegaonkar VS, Davange NN | Anaesthesia Management of a Phenytoin Induced Gingival Overgrowth (PIGO) Using Video Laryngoscope in a Paediatric Patient with Cerebral Palsy- Case Report | Journal of Anaesthesia and Critical Care Case Reports | September-December 2024; 10(3): 11-13. https://doi.org/10.13107/jaccr.2024.v10.i03.252 |
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