Laryngectomy

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sevoflurane

sevoflurane

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Quick question for y'all:

Would you induce a laryngectomy case without personally looking at a Head and Neck CT or CT report?

55 y/o female, 45 kg, skin and bones. 3ppd most of her life. She needs to take a breath between her barely audible sentences. Room air sats 88%, mild tachypnea. CXR is typical of mod-severe ephysema: bilaterally hyperlucent lungs of large volume, flattened hemidiaphragms with widened costophrenic angles, horizontal ribs, and a narrow mediastinum. No "acute process". FEV1 of 1100. FEV1/FRC 28% of predicted. No flow volume loop. Prolly has chronic hypoxic erythocytosis with a of hct 58. She makes Ma on Ma’s Roadohouse sounds like a Christina Aguilara:

[YOUTUBE]http://www.youtube.com/watch?v=wO4mBPsUQWM[/YOUTUBE]:laugh::laugh: (love that girl)



She show’s up for laryngectomy. No CT scan (done at outside hospital). Surgeon says tumor is below the epiglottis and spreads below the vocal cords. No radiation as of yet. It is scheduled for after laryngectomy.

  • Plan is for the trach to go in mid case after dissection. Surgeon doesn't think intubation will be a problem. I generally trust him, but nothing is for sure.
  • Patient doesn't want an awake trach under local (yeah... I know not the patients call).

Anyone cancel this case if you didn’t have a CT to look at? Just curious as I've alwyas had a CT available when planing an anesthestic for these individuals.
 
sure, I'll proceed with an awake fiberoptic intubation otherwise ct scan in hand.
 
Instead of cancelling the case, you could do a preoperative endoscopic airway exam as described by Rosenblatt:

Anesth Analg. 2011 Mar;112(3):602-7. Epub 2010 Nov 16.
Preoperative Endoscopic Airway Examination (PEAE) Provides Superior Airway Information and May Reduce the Use of Unnecessary Awake Intubation.

Rosenblatt W, Ianus AI, Sukhupragarn W, Fickenscher A, Sasaki C.
 
proman said:
Instead of cancelling the case, you could do a preoperative endoscopic airway exam as described by Rosenblatt:

Anesth Analg. 2011 Mar;112(3):602-7. Epub 2010 Nov 16.
Preoperative Endoscopic Airway Examination (PEAE) Provides Superior Airway Information and May Reduce the Use of Unnecessary Awake Intubation.

Rosenblatt W, Ianus AI, Sukhupragarn W, Fickenscher A, Sasaki C.
Click to expand...

Can anybody provide a link to the .pdf of that article? Thanks.
 
If you're going to do the exam, why not put a tube on the end of it and slip it down the trachea while you're at it.
 
Nice proman. I hadn’t thought about that. I wish I would have. I am assuming a nasal fiberoptic look with one of these little ENT toys:

op2.jpg


Admittedly, I haven’t done one of those since my ENT rotation as a resident. I only placed a handful of nasal fiberoptics over the last couple of years (I really don’t bust out the FO anymore unless I’m doing a Vats/lobectomy).

I guess my questions would be:

  • Could you piss off her tumor by poking around making things a bit more swollen before formally securing the AW? I don’t think so, but maybe.
  • What can it tell you about the subglottic tumor extension? No much, unless you are trying to navigate through the tumor to get into the trachea and check out the lay of the land. Not sure I’d want to do that 15 minutes before I plan on taking her back to the OR.

It can certainly give you a lot of information if you look down from the nasopharynx and see an absolute mess. Very useful in that situation or in the reverse situation where it looks like an easy passage into the trachea. Again, I wish I would have thought about that in the absence of a CT. 👍

KungPowChicken has a good point although he has committed himself to do an AFOI. So there is an assumption that he will get ETCO2 smoothly. This lady has a room air sat of 88% and little respiratory reserve. I would say this is a perfectly sound idea although the level of stimulation may be more than that of the nasal look and that AFOI doesn't guarantee a successful intubation within a reasonable amount of time. AFOI is completely reasonable.
 
So just for the sake of discussion, say you looked down and instead of seeing this:

laryngeal_myasthenia.jpg


You saw the attached picture (which is the actual laryngeal tumor):

Tumor extension through most of the Epigllottis.
Tumor invades the entire right hemi glottic area from where the epiglottis would be down and through the vocal cords.
No evidence of vocal cords anywhere.
Left hemi glottic area also affected, but there appears to be a small area that is begging for a tube. Problem is, you can't see past it. Might there be tumor growth somewhere beyond that point?

Arytenoids are really the only decently normal structures.

I would say that one of my fears when dealing with this airway was not knowing what was present below where the vocal cords should have been. A CT would have been nice. A piece of tumor catching on the end of my tube and it getting dislodged distally could have been problematic from a bleeding and more importantly a respiratory point of view. Not an issue with healthy lungs, but I suppose it could be a pain in the arse if a pice of tumor ended up obstructing a bronchus or plugging up a lobe in my lady.

What would you do if you had done an AFOI or a nasal scope and saw that picture?
 

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What you know on exam of the patient is that she is not stridorous or in respiratory distress so you can do an awake fiberoptic. On performing that if you see badness, meaning you get past the cords and there is this big mass in front of your eyes you bail and its awake trach time. No matter what you're going to look beyond the cords and if you're already there and it looks clear, put the tube in.
 
KungPOWChicken said:
What you know on exam of the patient is that she is not stridorous or in respiratory distress so you can do an awake fiberoptic. On performing that if you see badness, meaning you get past the cords and there is this big mass in front of your eyes you bail and its awake trach time. No matter what you're going to look beyond the cords and if you're already there and it looks clear, put the tube in.
Click to expand...

👍
 
I couldn't tell you the last time I did or even saw a total laryngectomy, but the ones I've done usually had a trach done under local first, then induction and proceed with the rest of the case.
 
Pent, sux, tube?

No, I agree with above, if surgeon is aware that tumor is all over epiglottis and VC, and the patient is obviously going to be trach'd as you've described, then "awake" trach sounds like Plan A, with a lot of coaching and a little midazolam/dexmed.

In preop I'd want to make sure that two things had been communicated with the patient:
a) you're gonna get a trach whether you like it or not
b) you may be on positive-pressure ventilation for a prolonged time after this surgery
 
I did a case not unlike this as a resident. ENT said no awake trach because he'd have to go through tumor to get to the trachea. Treated it like a mediastinal mass - slow inhalation induction, maintained SV, asleep FOI, done.

Well, actually I flailed at the FOI x1 attempt then my attending hip-checked me lest I bloody things up, then made it look easy. My CA1 thumbs couldn't execute but the plan was simple and sound.
 
fakin' the funk said:
Pent, sux, tube?

No, I agree with above, if surgeon is aware that tumor is all over epiglottis and VC, and the patient is obviously going to be trach'd as you've described, then "awake" trach sounds like Plan A, with a lot of coaching and a little midazolam/dexmed.

In preop I'd want to make sure that two things had been communicated with the patient:
a) you're gonna get a trach whether you like it or not
b) you may be on positive-pressure ventilation for a prolonged time after this surgery
Click to expand...

i tell this to everybody as a possibility, but i would bet this patient is on trach collar almost immediately
 
Yep. Less dead space and less work of breathing. She was pulling 8-10cc/kg at the end of the case. Asking for a pen and paper as monitors were being placed in pacu. Didn't seem to be as painful as I thought it could have been. I guess it makes sense as the recurrent and superior laryngeal were cut/removed.
 
So I guess no one would cancel the case due to lack of a head and neck CT.
I didn't either although I thought to myself "this is a completely elective case". I had and ENT in the OR, so I had a bail out strategy if things got bad.

She got glyco and 6mg of decadron 30 minutes before I took her in.
Titrated 20mcgs of precedex, 3cc' + 3cc's of propofol, and sevo while maintaining SV.
Not knowing what I was going to see I had a glidescpoe and fiberoptic ready to go.
DL X 1 with mac3. Wanted to tube her, but couldn't see past the tumor. Backed out and went for the glidescope to get a closer look. Up close and on the screen, the anatomy was a lot more clear. Had a 6.5 styleted ETT in hand. Came in from the right and gently pushed the tumor bed to the right with the tip of the ETT. It gave me a view into the trachea which showed tumor along the walls but not obstructing the central canal.

We only do 15-20 of these a year and there are 10 of us in our group. So we don't do these often.

Fun case. Different view to the base of the tongue and esophageal mucosa once sliced open.
 

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i think we get spoiled because our ENt group does probably 80-100 of these cases per year and every one of them has endoscopic exam in clinic with photos in the chart.

for this, you did it as i would have. honestly an awake trach is less trouble than an awake FOI in my opinion, and what is your plan if she refuses awake FOI too?

i feel the thing that must be assessed here is the amount of dynamic airway obstruction that exists. in patients that have fixed obstruction, you can get a tube in, because they can move air. it just might be a pediatric tube. however in patients who have been getting worse acutely, who cant breathe when they lie flat (not because of CHF) or who require BIPAP to stay alive because of their ball-valve tumor, i would keep awake. otherwise, this fixed mass just surrounds a hole that air goes through. if they are maskable (sounds like she was) they go to sleep and get some form of DL with ENT nearby...get your small tubes out, be ready to jet, dont burn any bridges,

1mg versed
sevo induction
take over masking
prop/vec
DL/video DL -> tube

i say vec because the last thing you want is for your sux to wear off after multiple views...if she cant be masked after sux, its not like you can wake her up anyway, so youll be slashing at that point
 
sevoflurane said:
  • Could you piss off her tumor by poking around making things a bit more swollen before formally securing the AW? I don’t think so, but maybe.
  • What can it tell you about the subglottic tumor extension? No much, unless you are trying to navigate through the tumor to get into the trachea and check out the lay of the land. Not sure I’d want to do that 15 minutes before I plan on taking her back to the OR.
Click to expand...


  • I think you should be able to get a view down the cords without coming too close.

    KungPOWChicken said:
    What you know on exam of the patient is that she is not stridorous or in respiratory distress so you can do an awake fiberoptic. On performing that if you see badness, meaning you get past the cords and there is this big mass in front of your eyes you bail and its awake trach time. No matter what you're going to look beyond the cords and if you're already there and it looks clear, put the tube in.
    Click to expand...

    The main utility is to do it before the OR so the decision of FOI vs DL is already settled. Also helps prepare the patient. I've found the hardest part of doing a smooth awake FOI is to get the cords/trachea well anesthetized. The nose and pharynx should much easier to get. Also, the scopes are smaller and you aren't shoving an endotracheal tube in either. Overall I think this approach would give you information that would convince the ENT and patient to do it your way.
 
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