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USAnesthesiaDoc

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Just had this one on call last night. What would you do?

59 year old man with history of CABG, EF 40%, s/p gastric bypass with 150 lb weight loss now weighing 140 lbs, with newly diagnosed tonsillar pillar cancer. The 6 cm mass is in his right tonsillar fossa and is locally metastatic to his right cervical lymph node and parapharyngeal area, which has resulted in complete inability to open his mouth. He cannot even get a straw between his teeth. Recent fiberoptic exam (1.5 months ago) by ENT revealed a normal base of tongue and nasopharynx and large eroding mass at the anterior tonsil extending to the soft palate; there is invasion of the right parapharyngeal space and the masticator space. CT of the neck reveals no pathology at the level of the vocal cords or below. There is extensive adenopathy of his right neck.

He was not considered surgically resectable, but is scheduled to start XRT. First he needs to have an infusaport placed, an open gastrostomy tube placed, and his right inguinal hernia repaired. All 3 procedures are scheduled for him to be done in one OR by the same surgeon.

The patient is extremely cooperative.

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Just had this one on call last night. What would you do?

59 year old man with history of CABG, EF 40%, s/p gastric bypass with 150 lb weight loss now weighing 140 lbs, with newly diagnosed tonsillar pillar cancer. The 6 cm mass is in his right tonsillar fossa and is locally metastatic to his right cervical lymph node and parapharyngeal area, which has resulted in complete inability to open his mouth. He cannot even get a straw between his teeth. Recent fiberoptic exam (1.5 months ago) by ENT revealed a normal base of tongue and nasopharynx and large eroding mass at the anterior tonsil extending to the soft palate; there is invasion of the right parapharyngeal space and the masticator space. CT of the neck reveals no pathology at the level of the vocal cords or below. There is extensive adenopathy of his right neck.

He was not considered surgically resectable, but is scheduled to start XRT. First he needs to have an infusaport placed, an open gastrostomy tube placed, and his right inguinal hernia repaired. All 3 procedures are scheduled for him to be done in one OR by the same surgeon.

The patient is extremely cooperative.

Is his inability to open his mouth a mass issue, or pain issue? You may be able to do a fiberoptic nasal intubation. Probably an awake trach is the best thing but since this is a short procedure and probably his only time to the OR, it seems overkill if you can get a tube nasally.
 
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He is going to need a tracheostomy soon so why wait??

That was my first reaction as well. However, after an extensive discussion with the patient and surgeon, we decided to do the case under local/MAC. As I mentioned, the patient was very motivated and cooperative and he wanted to avoid a trach and get these procedures done so that he could start his radiation. The surgeon is quite good and quick and had done open G tubes in the past under local. Also, there were no plans for him to get a trach. His radiation oncologist thought that if the tumor responded well to XRT, he might be able to open his mouth again to some degree, and he was getting the G tube in order to receive nutrition. There was currently no immediate airway compromise. We all agreed that if at any point the patient could not tolerate anything, we would quit the procedures and he would come back at a different time under GA after a probable trach. We had a long discussion about the risks to his airway even with sedation, and that the patient would essentially only receive conscious sedation (ie be conversant throughout). I titrated small amounts of versed and fentanyl throughout and much to the patient's credit, we actually accomplished all 3 procedures.
 
The dude is gonna buy a trach. He should have one first. Then do his other procedures the same day. Christ, the guy can have a fenestrated trach and talk through the damn thing.

If he cant even open his mouth to eat what happens in the future (as in at home) if he pukes? Or coughs real hard and brings something up? Or gets a pharyngeal infection. This guy is a walking disaster. He needs to have this explained to him

I'm all for cosmetic appreciation. Believe me. I'm certain the guy doesnt wanna walk around with a trach. Wear a TURTLE NECK. Yeah it sucks but you know what sucks more? Goin to the ER. To have this guy in the ER from an upper resp infection, OR post radiation edema, OR whatever is GOING TO BE A DISASTER.


Awake trach. General. Then finish everything else off.
 
Is his inability to open his mouth a mass issue, or pain issue? You may be able to do a fiberoptic nasal intubation. Probably an awake trach is the best thing but since this is a short procedure and probably his only time to the OR, it seems overkill if you can get a tube nasally.

You gonna ram the tube past his huge pharyngeal tumor and have it bleed. Forget it.

An emergency is one thing but not this.
 
anybody who wants to delay a trach on this guy is a fool....

the trach can be reversed
he can still phonate with a trach...

no big deal

do it awake - especially since he is cooperative.

otherwise he should make himself a DNR
 
You gonna ram the tube past his huge pharyngeal tumor and have it bleed. Forget it.

An emergency is one thing but not this.

You don't have to ram it. :D

As soon as you gently touch the necrotic tumor it will bleed like stink. Now you get to do a crash trach. You are absolutely right on this Venti.
 
His radiation oncologist thought that if the tumor responded well to XRT, he might be able to open his mouth again to some degree, and he was getting the G tube in order to receive nutrition.

Let me assure you, with that tumor his trismus will get worse with XRT, not better. The pterygoids are invaded and he is a T4. That tumor needs chemo and XRT if they are going for cure. Chemo = nausea/vomiting. Trismus + N/V - trach = death.

Recent fiberoptic exam (1.5 months ago) by ENT revealed a normal base of tongue and nasopharynx and large eroding mass at the anterior tonsil extending to the soft palate; there is invasion of the right parapharyngeal space and the masticator space.

Why the delay??? 6 weeks since the tumor was diagnosed and still hasn't started treatment??? And this guy is worried about his hernia??? This is a case of total denial...very common in head and neck cancer.

He needs an awake trach and a very frank discussion about his prognosis (< 10% 5 year survival) with a head and neck surgeon. His radiation oncologist is obviously clueless.
 
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