Key points Laryngectomy is performed in specialist centres and requires a team approach to airway management. Laryngeal cancer patients frequently have cardiac and respiratory co-morbidities with limited scope to optimize. Anaemia, malnutrition, and alcohol dependency are modifiable preoperative risk factors. Acute presentations with stridor require a collaborative approach to the airway that only rarely involves awake fibre-optic intubation. Post laryngectomy patients can present for other types of surgery and a clear plan must be made for the management of such patients.
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Key points Laryngectomy is performed in specialist centres and requires a team approach to airway management. Laryngeal cancer patients frequently have cardiac and respiratory co-morbidities with limited scope to optimize.
Anaemia, malnutrition, and alcohol dependency are modifiable preoperative risk factors. Acute presentations with stridor require a collaborative approach to the airway that only rarely involves awake fibre-optic intubation. Post laryngectomy patients can present for other types of surgery and a clear plan must be made for the management of such patients. Total laryngectomy is the en bloc removal of the laryngeal structures including the epiglottis, hyoid, and a variable amount of upper trachea.
The resultant defect requires creation of a permanent tracheostomy tracheostome and repair of the pharynx. It is usually performed for advanced cancer of the larynx either as a primary treatment or for surgical salvage following failure of laryngeal preservation treatments radiotherapy or concurrent chemoradiotherapy. Laryngectomy can also involve concomitant neck dissections, and in some cases pharyngeal reconstruction requires reconstruction with pedicled flaps or free tissue transfer.
Undergoing laryngectomy is a life-changing procedure. The patient must learn a new method of communicating, they become a neck breather, and undoubtedly, it alters their body image perception. Before surgery, all patients are given the opportunity to meet another patient who has undergone the procedure to increase their understanding of the changes in appearance and communication they will experience. Patients can be in hospital for up to 2 weeks following laryngectomy, and this period can be a difficult time, with feelings of depression and isolation.
Each patient should have access to a clinical nurse specialist in head and neck cancer, who can provide valuable support at each stage of the patient journey. Laryngeal cancer Laryngectomy is an effective cancer procedure and is associated with good functional outcomes.
This is for patients with T3 tumours on the tumour—nodes—metastases TNM scale. For patients with T4 disease invading the laryngeal cartilages, total laryngectomy is recommended. Although laryngeal preservation may seem preferable, these cases require careful discussion at a regional head and neck cancer multidisciplinary team meeting, as evidence is emerging that patients who undergo primary surgery have improved survival rates.
Rates are highest in Scotland and Northern Ireland. Smoking and alcohol consumption are risk factors. Consequently, patients presenting with laryngeal cancer are often older with multiple co-morbidities. National guidelines recommend that laryngectomy is performed in specialist centres, as complication rates are lower in departments that perform this procedure frequently. The anaesthetist can be involved with these patients at any stage of the disease, both in the elective and emergency setting.
The most challenging aspect can be intubation of the post-radiotherapy patient. It is therefore important to understand the disease process and the management of these cancers in order to formulate an appropriate anaesthetic management plan. The overwhelming message when managing these patients is that there must be open lines of communication with the surgeon and wider team. Surgical techniques Intubation of the patient can be challenging for laryngectomy.
There has been a move in practice away from performing preoperative tracheostomy, because this procedure is associated with poorer wound healing, particularly in patients who have undergone radiotherapy.
There is also a higher rate of tracheostomal cancer recurrence following pre-laryngectomy tracheostomy. The choice of tracheal tube depends on the bulk of the tumour, but generally a small reinforced tube is acceptable.
When the trachea is resected from the larynx, the tracheostome is formed on to the skin. At this point, the tracheal tube is withdrawn, and a laryngectomy anaesthetic tube e. This can be sutured on to the chest wall for security. At the end of surgery, it is a common practice to insert a cuffed tracheostomy tube for the first 24 h.
This is not surgically necessary but can help with suctioning and prevention of aspiration of blood after operation. Neck dissection is frequently performed at the same time as total laryngectomy. This procedure was introduced in as a radical en bloc resection of all of the nodal tissue of the neck including the sternocleidomastoid muscle, the internal jugular vein, and the spinal accessory nerve.
Today the most common form of neck dissections performed are modifications of the radical neck dissection preserving one or more of the non-lymphatic structures or selective neck dissections.
Selective neck dissection aims to remove a portion of nodes most at risk for metastases for any cancer site in the head and neck. For laryngeal cancer, the most commonly removed surgical lymph nodes are those related to the jugular vein surgical levels 2—4. Other nodal stations are level 1 submental nodes , level 5 posterior neck nodes , and levels 6 and 7 these stations are also known as central compartment nodes and involve nodal tissue medial to the carotid artery below the level of the hyoid down to the superior mediastinum.
Complications of neck dissection include bleeding. If the internal jugular vein is ligated there is a resultant increase in intracranial pressure, and this is inevitably higher if both veins are ligated.
Nerve palsies are associated with neck dissection and may affect the marginal mandibular branch of the facial nerve resulting in lower-lip weakness , the hypoglossal nerve causing loss of movement of the ipsilateral tongue , or the accessory nerve resulting in stiffening and weakness of shoulder movements. Any loss of accessory nerve function, whether sacrificed or iatrogenically damaged, is managed by early and regular physiotherapy. The phrenic nerve is also at risk, leading to paralysis of the hemidiaphragm.
During selective neck dissection, the cervical plexus can be spared leading to less hypoaesthesia of the wound than anticipated. Injury to the thoracic duct may result in a leakage of chyle; this is recognized by the presence of a milky fluid in the surgical drains.
Initially, it is managed conservatively, with input from the nutrition team and a low- or no-fat diet that decreases production. High-volume chyle fistula requires total parenteral nutrition and surgical intervention. Clinical presentation Red flag presentation symptoms for head and neck cancer include persistent hoarseness, which is the most common presentation, with other symptoms and signs being dysphagia, odynophagia, otalgia, cervical adenopathy, or haemoptysis.
It is uncommon, but the first presentation may simply be acute stridor. Patients may present with stridor pretreatment because of tumour bulk or fixation of the larynx or post-treatment as a result of swelling following radiotherapy.
Anaesthesia for patients with laryngeal cancer The anaesthetic technique depends on the nature of the surgery, ranging from panendoscopy and laryngeal biopsy to more extensive laryngectomy or emergency tracheostomy in acute airway obstruction. Preoperative assessment Standard preliminary investigations should be performed.
In particular, iron deficiency anaemia should be treated. Preoperative anaemia is associated with poorer surgical outcomes and its optimization is an area with a growing body of evidence. While there is no specific literature pertaining to laryngectomy patients, the principles of iron replacement have been adopted by ENT UK in their recently published national guideline.
Cardiovascular disease This is common, given the patient demographics, with ischaemic heart disease being a frequent co-morbidity in laryngectomy patients. Cardiology specialist opinion may be helpful in those with unstable angina, recent stenting, decompensated heart failure, or severe aortic stenosis.
Respiratory disease Laryngectomy patients are frequently heavy smokers with significant associated respiratory disease. When there is significant laryngeal narrowing, pulmonary function tests are often unreliable. Particularly high-risk surgical candidates are those with pulmonary hypertension and right heart disease.
When these conditions are present, serious consideration should be given to whether these patients are surgical candidates. Cardiopulmonary exercise testing If cardiopulmonary exercise testing CPET testing is available, it may aid risk stratification.
Failure to achieve that level of exertion is associated with increased risk. Other considerations Controlled alcohol withdrawal as an inpatient combined with a period of nasogastric NG feeding can be instituted a week or two before surgery in order to undergo a controlled detoxification and improve nutrition in patients judged to be at high risk of alcohol withdrawal.
Percutaneous endoscopic gastrostomy feeding is rarely used, as the major aim of surgery is to rehabilitate swallowing as well as voice, and the temporary nature of postoperative NG or stomagastric feeding lends itself well to the short time periods involved. Postoperative management of alcohol withdrawal and administration of B vitamins should be considered. The vast majority of patients are smokers, so preoperative smoking cessation should be actively encouraged and nicotine replacement offered.
Knowing the risk Patients and anaesthetists are increasingly interested in risk stratification. Laryngectomy is considered to be intermediate risk surgery, as it does not involve opening of a major body cavity.
Neither have been validated for use in laryngectomy, but can be a useful guide when quantifying risk, particularly in the wake of the Montgomery ruling, 11 where informing patients of the risks and complications likely to affect them is vital.
Discussions about consent and our explanation of risk are topical and should, where possible, be tailored to the individual patients. Tools that aid our stratification of risk are helpful in shaping these discussions.
Optimization Other than controlled alcohol withdrawal and NG feeding as described above, there is a limited time in which to perform more extensive prehabilitation or optimization other than for routine management of cardiovascular or respiratory disease.
All patients with a head and neck cancer diagnosis in our institution have access to a specialist dietician and early referral is recommended in patients who have inadequate intake or who are losing weight. Planning airway management This is applicable for the elective patient and for those who may present in extremis with stridor. The surgical procedure undertaken in patients with laryngeal cancer ranges from panendoscopy and biopsy to laryngectomy and occasionally emergency tracheostomy.
Airway assessment Assessment of the airway incorporates history and bedside examination, review of imaging and nasendocopy findings as well as discussion with the surgical team.
History should focus on voice change, dysphagia, breathlessness, and stridor. It is useful to know whether the patient can lie flat and how they have been sleeping.
Difficulty sleeping or waking up with breathlessness are ominous signs of airway obstruction. The usual methods of airway assessment including mouth opening, tongue protrusion, mallampati scoring, thyromental distance, and neck movement should be recorded. Neck examination is essential; any previous radiotherapy, tracheal deviation, neck masses, and previous scars may indicate that intubation could be difficult.
Any anticipated difficulty with front of neck access should be noted at this time. Imaging This includes nasendoscopy imaging Fig. Note any points of narrowing, rigidity, or fragility of tissues or the presence of tumour that may obscure the laryngoscopic view.
Computerized tomography CT and magnetic resonance imaging are the mainstay of preoperative imaging. The axial images will show how narrow the airway is and the sagittal and coronal cuts can be used to estimate the length of any narrow segments. Fig 2 Examples of early and advanced laryngeal cancer seen during direct laryngoscopy. Useful questions to ask before you start … There is no single correct answer on how to manage these patients, as each case is different.
In our institution, we have found that answering each of the questions below can help formulate an airway management plan. How will I preoxygenate? Will I be able to use facemask ventilation FMV?
Will I be able to get a good view of the cords? Will I be able to intubate? How easy would front of neck access FONA be? Managing the emergency stridulous patient The intubation of these patients for their surgery is a significant challenge.
ANAESTHESIA FOR LARYNGECTOMY PDF
If face mask ventilation is likely following induction of general anaesthesia? If laryngoscopy and intubation are likely to be difficult? If an awake technique is more appropriate? If emergency surgical airway and front of neck access FONA is feasible?
Tygolkis Anaesthesia for total laryngectomy. Formal tumour assessment for treatment planning examination under anesthesia and biopsy This is the more usual situation where the risk of airway obstruction is considered less likely. Fluid management and blood loss Many resections and free tissue transfers will not be associated with significant bleeding, though this is not necessarily true for tongue and mandibular resections where brisk bleeding may occur. United Laryngectony National Multidisciplinary Guidelines. The use of muscle relaxant drugs to facilitate laryngoscopy in these cases is controversial because even if intubation conditions are improved this may be at the cost of greater risk of airway obstruction. General anaesthetic considerations World Health Organization WHO checklist All theatre staff are recommended to participate in this initiative to ensure that teams work effectively and that the right patients get the laryngecotmy surgical procedure they have consented to.