These include the effect of anesthesia on pulmonary mechanics, the supine body position, and the elimination of glottic regulation of airflow by endotracheal intubation. Suggested managment interventions include awake fiberoptic intubation, placement of the endotracheal tube as near to the carina as possible, maintenance of spontaneous ventilation as long as possible, changes in patient position, avoidance of general anesthesia, availability of cardiopulmonary bypass, preoperative radiation therapy, corticosteroids, and positive end-expiratory pressure. Most of these would not have been of any benefit to out patient, although a left-sided endobronchial tube was considered. The cystic nature of our patients mass presented another option, transcarinal decompression. The diagnostic use of a transbronchoscopic needle aspiration of a mediastinal cyst was reported by Barzo and Gyulai in 1975.

Schwartz et al reported the therapuetic use of transbron-chial needle aspiration for a bronchogenic cyst in 1986. We believe this is the first report of the intraoperative therapeutic use of the same technique. The patient whose case is reported herein, despite minimal symptoms preoperatively, exhibited ventilatory difficulty with a large alveolar-arterial gradient immediately after induction of anesthesia and endotracheal intubation. This could only have been expected to worsen after turning to the left lateral position and performance of a right thoracotomy. Endoscopic deflation of the cyst allowed for more effective ventilation and made the subsequent anesthetic management easier and safer. We do not suggest that this technique should take the place of surgical resection.