Extensive Cervicofacial Lymphatic Malformation With Hemorrhagic Component in a Neonate: Airway and Anesthetic Challenges in Surgical Management

Lymphatic malformations (LMs) are benign lesions common in infancy and early childhood. Massive hemorrhage in LMs is associated with high morbidity. A full-term male neonate, born through spontaneous vaginal delivery to an unbooked 25-year-old mother, presented with a large, bluish cystic swelling involving the anterior neck and floor of the mouth. The neonate exhibited weak crying, oral bleeding, and airway obstruction with tongue protrusion. Initial airway support with continuous positive airway pressure was unsuccessful. The airway was secured with a 3.5-mm uncuffed endotracheal tube, as confirmed by capnography and chest radiography. Computed tomography showed a large, multiloculated anterior neck cystic lesion with internal hemorrhagic components and marked mass effect, causing near-complete oropharyngeal obstruction. Magnetic resonance imaging revealed extensive macro- and microcystic LMs with venous components involving the tongue, floor of the mouth, and parotid spaces, extending inferiorly to the thoracic inlet. Laboratory results revealed anemia and coagulopathy. Neck exploration, partial debulking, and tracheostomy were performed, with full preparation for massive transfusion. On day 5 of life, neck exploration with partial resection of the cystic mass and tracheostomy (3.5-mm tube) was performed under general anesthesia. The infant developed postoperative neck swelling secondary to a hematoma, which was evacuated at the bedside with a favorable outcome. The tracheostomy remained patent, and facial and tongue edema gradually resolved. The patient received a provisional diagnosis of lymphatic-venous malformations. Cervicofacial LMs may arise in infants experiencing airway difficulties. Spontaneous ventilation maintenance until securing the airway, meticulous preoperative planning, and multidisciplinary collaboration are essential for safe perioperative management.