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Clinical Practice Guidelines

Oncological emergencies: Mediastinal mass

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    PIC Endorsed

  • See also

    Acute upper airway obstruction
    Minimising distress in healthcare setting
    Fever and suspected or confirmed neutropenia
    Hyperleukocytosis

    Key points

    1. Children with a mediastinal mass on CXR require urgent escalation of care to a tertiary paediatric hospital. Promptly involve retrieval services and oncology
    2. Sedation, general anaesthesia and all invasive procedures should be carefully planned to minimise risk of airway compromise

    Background

    Children with mediastinal masses are at risk of acute respiratory deterioration, and may rapidly become critically unwell

    Assessment

    History

    • Noisy breathing consistent with stridor or wheeze
    • Orthopnoea (difficulty lying flat on back to sleep at night)
    • Bone pain
    • Collapse or dizziness

    Examination

    • Keep the child comfortable, allow them to adopt position of comfort (see Minimising distress in healthcare setting). Do not force the child to lie flat
    • Examine for stridor or wheeze which suggest airway obstruction
    • Examine for signs of pericardial effusion or tamponade, including distention of jugular veins, muffled heart sounds, and low blood pressure
    • Check for SVC obstruction and Pemberton's sign (ask the child to elevate both arms to touch the sides of the face; a positive sign is facial congestion, cyanosis and respiratory distress)
    • Examine for organomegaly or lymphadenopathy

    Management

    • Facilitate urgent retrieval to tertiary paediatric hospital, in discussion with oncology and PICU

    Investigations

    • Consider discussion with oncology prior to taking further bloods to minimise repeat sampling. Bloods will include peripheral blood flow cytometry (which may be diagnostic)
    • Lateral CXR to assess location of mass
    • If the child can lie flat comfortably, consider CT chest
    • If available, urgent echocardiogram and cardiology opinion

    Treatment

    • Sedation, general anaesthesia and all invasive procedures should be carefully planned to minimise risk of airway compromise, see Acute upper airway obstruction
    • Commence hydration as per oncology advice
    • Do not commence corticosteroids without consultation with oncology

    Consider consultation with local paediatric team when

    All children with a mediastinal mass

    Consider transfer when

    All children with new diagnosis or symptomatic mediastinal mass should be managed in a centre with paediatric intensive care support

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Last updated December 2025

    Reference List

    1. Bohm A et al. Timely diagnostics and safe procedures in children with anterior mediastinal masses (AMMs): a qualitative review of the AMM protocol at BC Children's Hospital in Vancouver BC. Pediatric Hematology and Oncology. 2023. 40(1), p51-64.
    2. Pearson J et al. Pediatric Anterior Mediastinal Mass: A Review Article. Seminars in Cardiothoracic and Vascular Anesthesia. 2015. 19(3), p248-254.
    3. Tan A et al. Anesthesia for children with anterior mediastinal masses. Paediatric Anesthesia. 2022. 32(1), p4-9.