Larynx/Trachea

Question 1

On what factor is the decision to perform a partial

versus a total laryngectomy made?

Answer 1

If at least one of the cricoarytenoid units is spared, then the
patient may be a candidate for a partial laryngectomy. A
cricoarytenoid unit consists of a properly innervated posterior
cricoarytenoid muscle and functional cricoarytenoid joint.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 203.

Question 2

Is the thyroid gland removed in a total laryngectomy?

Answer 2

The thyroid gland may be preserved during a total laryngectomy.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 205.

Question 3

Is a tracheostomy tube required following a total

laryngectomy?

Answer 3

Because the trachea is anastomosed directly to the skin
surface, a tracheostomy tube or ETT is not necessary unless
the patient has severe stomal edema or will require
postoperative mechanical ventilation, which is typically not the
case.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 205.

Question 4

Is a tracheostomy tube required following a partial

laryngectomy?

Answer 4

A tracheostomy tube will be needed following a partial
laryngectomy.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 203.

Question 5

Is the use of muscle relaxants contraindicated in

patients undergoing a laryngectomy?

Answer 5

No, in fact, full muscle relaxation is crucial during the procedure.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 206.

Question 6

What is the most common reason for performing a

laryngectomy?

Answer 6

Squamous cell carcinoma of the larynx
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 203.

Question 7

You have awakened a patient who underwent a
tracheal resection and extubated him. The patient is
able to phonate normally. The surgeon asks for a
fiberoptic laryngoscope. Does he suspect a
problem?

Answer 7

Not necessarily. After extubation, the standard of care is to
perform a fiberoptic laryngoscopy to verify that both vocal folds
are mobile.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 201.

Question 8

Would it be more appropriate to maintain a patient in
Trendelenburg or reverse Trendelenburg position
during a tracheal resection?

Answer 8

During this procedure, the resection may be performed around
an endobronchial or double-lumen tube and the patient should
be kept in the head-down position to prevent aspiration of blood
and surgical debris.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1064

Question 9

A patient undergoing a tracheal resection requires
continuous vasopressor administration and you
decide to start an arterial line to monitor his blood
pressure. Where should you place it and why?

Answer 9

An arterial line should be placed in the left radial artery to
provide continuous monitoring of blood pressure during periods
of compression of the innominate artery.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1064.

Question 10

How should you adjust the FiO2 during a tracheal

resection for the greatest degree of patient safety?

Answer 10

During tracheal resection, a high FiO2 should be maintained
throughout the case to ensure adequate oxygenation of the
functional residual capacity so temporary interruptions in
ventilation are tolerated without hypoxia.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1064.

Question 11

What is the most common indication for tracheal

resection?

Answer 11

Tracheal stenosis
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 200-201.

Question 12

Bilateral vocal fold paralysis may be a complication
of a tracheal resection. Can a patient with bilateral
vocal fold paralysis speak?

Answer 12

Yes. Phonation and normal voice quality does not exclude the
possibility of bilateral vocal fold paralysis. The voice is often
normal and the only symptoms are dyspnea and stridor.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 201.

Question 13

What are the typical indications for performing a

cricotracheal resection?

Answer 13

It is most often performed for a subglottic stenosis or a
combined subglottic-tracheal stenosis.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 201.

Question 14

What structures are at risk for damage from a

tracheotomy?

Answer 14

The three cartilages that compose the larynx: the epiglottis, the
thyroid, and the cricoid cartilage can become damaged. The
cricothyroid membrane that stretches between the thyroid and
cricoid cartilages can become injured. The cricothyroid and
vocalis muscles attach to the vocal cords off of these cartilages
and are susceptible to damage during the cricothyrotomy
procedure. The innominate artery and inferior thyroid veins are
also at risk of damage during surgical access to the trachea.
Lastly, the recurrent laryngeal nerve is at risk of damage during
dissection.
Lindman JP. Tracheostomy. [Online] July 24, 2008
.

Question 15

During tracheal dissection for a tracheotomy on an
intubated patient, the inflated endotracheal tube cuff
is at risk for damage. What is the most prudent
method to prevent damage to the cuff?

Answer 15

As the surgeon enters the trachea, there is risk of damage to
the endotracheal tube cuff from either the scalpel or an
electrocautery unit. The most prudent method of reducing this
risk is to advance the tube toward the carina so that as the
trachea is entered surgically, the cuff is well below the surgical
site.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 192.

Question 16

What cartilages compose the larynx?

Answer 16

Three cartilages compose the larynx: the epiglottis, the thyroid,
and the cricoid cartilage.
Lindman JP. Tracheostomy. [Online] July 24, 2008
.

Question 17

The surgeon is having difficulty placing a
tracheostomy tube and asks you to reinsert the
endotracheal tube to ventilate the patient while he
prepares to try again. You are unable to insert the
endotracheal tube, however, and the patient’s
oxygen saturation is declining. What airway options
should you consider at this point?

Answer 17

A rigid bronchoscope should always be available during a
tracheostomy to re-establish the airway in the event reintubation
with the endotracheal tube fails. If this is unavailable, you
should consider inserting a large-bore IV into the trachea distal
to the surgical site and initiate jet-ventilation. Some clinicians
advocate the placement of an airway exchange catheter
through the endotracheal tube prior to removing it in the event
the airway should need to be emergently re-established.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 193

Question 18

What types of incisions would you expect to see for
tracheotomy in adults? What about pediatric
patients?

Answer 18

In adults, a small transverse incision may be made about 1-2
cm below the cricoid cartilage. Alternatively, a vertical incision
originating at the same position may be used. In small children,
only the vertical incision is used because the transverse incision
is associated with a higher risk of subglottic stenosis.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 190.

Question 19

What are the three main populations of patients that

present for tracheostomy?

Answer 19

Critically-ill patients, patients who are undergoing a
tracheostomy as part of another procedure such as
laryngectomy, and patients with upper airway obstruction.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 191

Question 20

Positioning for a tracheostomy often requires the
placement of a roll under the patient’s shoulders to
extend the neck. How can this affect the position of
the endotracheal tube?

Answer 20

Extension of the neck can cause the endotracheal tube to
migrate more cephalad. This can place the ETT cuff closer to
the site of incision and increase the risk for inadvertant puncture
of the cuff. It is important to securely tape the endotracheal
tube to prevent excessive migration.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 192

Question 21

During a tracheostomy, the surgeon inserts the
tracheostomy tube and you connect the anesthesia
circuit to it. You immediately notice a high peak
inspiratory pressure, a lack of end-tidal CO2, and
absent breath sounds. What do you suspect may be
the cause and what should be done?

Answer 21

It is possible that the surgeon has placed the tracheostomy tube
in a false passage in the tissue rather than in the trachea. You
should immediately attempt to reinsert the endotracheal tube.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 192.