Extra Topic 6.5 -- Laryngectomy

Question 1

How would you evaluate this patient airway preoperatively?

(A 68-year-old male, present for total laryngectomy to remove a glottic mass after failed radiation therapy. He is an alcoholic who has been smoking cigarettes for over 40 years.)

Answer 1

Given the potential for difficult intubation and ventilation, I would:

1. perform a standard airway exam, including mouth opening, neck range of motion, thyromental distance, etc.;
2. review the surgeons notes from the most recent fiberoptic and mirror inspection, to help identify the extent of the mass;
3. look at the most recent CT scan of his neck to identify and assess the extent of airway compromise;
4. palpate the patient’s neck to identify any masses and/or tracheal deviation, and to assess tissue plasticity (the latter may be affected by mass affect and/or radiation therapy); and
5. further examine the patient for signs of airway obstruction, such as stridor, hoarseness, dyspnea, sternal retraction, and the use of accessory muscles of respiration.

Question 2

On exam, you note stridor, sternal retraction, and the use of accessory muscles of respiration. Would you perform an awake fiberoptic intubation?

(A 68-year-old male, present for total laryngectomy to remove a glottic mass after failed radiation therapy. He is an alcoholic who has been smoking cigarettes for over 40 years.)

Answer 2

While an awake fiberoptic intubation is often utilized in the management of a known or anticipated difficult airway, it may not be the best approach in the setting of advanced obstructive laryngeal disease due to:

1. the risk of complete obstruction as the fiberscope passes through the mass;
2. the difficulty of achieving adequate airway analgesia in the setting of advanced laryngeal pathology; and
3. the technical difficulty of performing fiberoptic intubation through a large vascular friable tumor (i.e. tortuous route, bleeding, and/or edema).

Therefore, I would consider one of the following options:

1. an inhalational induction with the goal of maintaining spontaneous ventilation until the airway was secured;
2. placement of a transtracheal catheter under local anesthesia, followed by intravenous induction and jet ventilation through the catheter; or
3. an awake elective tracheostomy under local anesthesia.

Question 3

Later that night you are called to the ICU because the patient’s tracheostomy tube was accidentally removed.

Your attempts to reinsert the tracheostomy tube are unsuccessful. What would you do?

(A 68-year-old male, present for total laryngectomy to remove a glottic mass after failed radiation therapy. He is an alcoholic who has been smoking cigarettes for over 40 years.)

Answer 3

Recognizing that there is no longer a communication between the oropharynx and the lower trachea in a patient who has undergone total laryngectomy,

I would have someone call for a surgeon capable of obtaining emergency airway access.

In the meantime, I would attempt to oxygenate and ventilate the patient via a partially inflated LMA applied over the stoma site, or jet ventilation through a catheter inserted into the stoma.

Key Topics & Clinical Considerations:

1. Neck Surgery –

• Current Topics in Anesthesia for Head and Neck Surgery (Fleisher): (pg 529-538)
• Miller’s Anesthesia – 7th ed.: (pgs 2375-2378)