Anesthesia consideration for laryngectomy

2. Laryngectomy
• 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.

3. • Total laryngectomy is the 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.

4. Examination
• GPE
• Built / nutritional status
• Vitals
• Oral cavity
• Jugular venous pressure
• Respiratory system –wheeze
• Airway examination: distorted upper airway and obstructed, because
of friable growth with or without tracheostomy.

5. Investigations
• Routine
• Haemogram , blood glucose, KFT, LFT, SE
• Urine routine,
• ECG
• Specific: to assess extent, invasion, destruction
• Chest X–ray PA
• X–ray neck – AP / Lateral
• Indirect laryngoscopy
• PFT (COPD)
• Laryngogram filling defect:
• CT scan, barium swallow
• MRI

6. Preoperative preparation
• Optimize lung functions:
• antibiotics, bronchodilators, corticosteroids, chest physiotherapy
including breathing exercises
• Care of nutrition, hydration
• Removal of bad teeth
• Indirect laryngoscopy - review again
• Treatment of associated medical disorders and age related problems
• Counseling-post operative speaking
• Care of tracheostomy

7. Preoperative preparation
• Cessation of smoking
• Time course beneficial effects
• 12-24 hours ↓CO and nico ne levels
• 48-72 hours ↓COHb levels normalizes and bronchociliary functions
improve
• 1-2 weeks sputum production
• 4-6 weeks PFT improves
• 6-8 weeks immune function and drug metabolism normalize
• 8-12 weeks ↓overall PO morbidity

8. Patient Preparation
Anesthesia
• Prior to the induction of anesthesia, an airway management plan is
coordinated with the anesthesiology team. In patients with bulky,
airway obstructing tumors, an awake tracheotomy may need to be
performed. In these cases, the tracheotomy should be performed
using local anesthesia in the area of the planned laryngostoma. Once
general endotracheal anesthesia is induced, the eyes should be taped
shut and padded

9. Cessation of alcohol
• effect on liver, gastric irritation, CVS, therefore pre-medication with
antacids and metachlorpromide
• Effects Acute Chronic
• inhala onal agents, ↓ need ↑MAC
• barbi+benzo+opioids more sensitive cross-tolerance
• suxamethonium - ↑effect
• relaxants: rely on hepatic clearance
• drug of choice: atracurium

10. Preoperative advice
•
NPO, continue bronchodilators + morning dose of drugs, arrange
blood, consent
• Pre-medication – Glycopyrrolate 0.2 – 0.3 mg i/m, nasal drops ± FOB,
± IL, sedatives ±
• If with tracheostomy: steam, nebulisation, encourage cough, suction,

11. Surgical plan
• Direct laryngoscopy and biopsy (day care)
• Major surgery
• Partial / total laryngectomy
• Laryngo-pharyngectomy
• RND
• Flap surgery
• Besides normal routine check for Int.
• Stylet , MLS tube
• Tracheostomy set
• Local: 2%, 4%, 10% for awake intubation
• Availability of defibrillator
• Other type and size of laryngoscope
• check the equipment like FOB
• Ready ENT surgeon

12. Major surgery
• Preoperatively arrange
• Blood, Ryle’s tube CVP line, Foley’s catheter
• If already tracheostomised
• Care of tracheostomy tube
• Montendo tube / Montgomery T – tube
• I/V access
• Premedication ±
• Preoxygenation
• Induction
• Propofol / Thiopentone
• Suxamethonium after mask ventilation
• Maintenance on O2, N2O , Halothane or Isoflurane

13. Monitoring
• Routine
• HR, ECG
• SpO2, EtCO2
• NIBP
• Temperature (rectal + axillary probes)
• In addition
• CVP (towards higher side)
• Urine output
• Blood loss
• Arterial line for serial estimation of blood gas and hematocrit
• Airway pressures
• Positioning – head up tilt (15 to 20 degree)

14. Intra-operative problems
• Bleeding (hematocrit 0.25 to .0.27)
• ↓by posi oning of pa ent (pillow under knees, reversed Trendelenburgh
position), 2 mmHg fall in BP for each 2-5 cm rise in head position above the
heart level.
• Induced hypotension – inhalational, i/v (NTG, SNP etc).
• Early, accurate assessment of blood loss: Timely replacement with blood /
colloid.
• Compromised cerebral circulation
• caro d artery infiltra on →↓cerebral arterial pressure
• jugular vein infiltra on →↑cerebral venous pressure
• rota on of neck →↓caro d blood flow

15. • Induced hypotension
• Inhalational
• Isoflurane
• dose dependent hyotensive effect by vasodilatation
• up to 40mmHg in 6 minutes, little change in CO
• Halothane/enflurane
• ↓ BP, CO, Stroke volume →↑right heart filling pressure
• IV agents
• fentanyl 1-3mcg/kg
• propofol 100mcg/kg/minute
• NTG 0.5-3mcg/kg (BP 80-90mmHg)
• SNP 3mcg/kg/minute, ↓es dias. by 30 to 40%

16. During opening of neck veins
• Rapid fall in EtCO2, BP → Air embolism
• ECG: inverted T, tall P, RBBB, RHS→VF
• Treatment
• Stoppage of surgery
• Flood with saline/fluid
• 100 % O2 , stop N2O- why?
• Durhant’s position
• Aspiration of air through CVP catheter
• PPV

17. • Carotid sinus stimulation → cardiac dysrhythmias, bradycardia,
Hypotension
• Denerva on of caro d sinus body→ hypertension and loss of hypoxic
derive.
• Ablation of rt sympathetic ganglion-↑QT interval and malignant
arrhythmias → cardiac arrest
• Treatment – LA infiltration of carotid bulb / vagolytic agents
• cessation of pressure

18. • Intra-operative maintain adequate analgesia
• When trachea is transected, tube is replaced by non kinkable tube
(confirmed by capnography and auscultation)
• ↑ airway pressure: malpositon of tube, bronchspasm, debris
• Loss of airway at induction, midway, extubation, postoperative
• Postoperative problems
• Prolonged recovery – ICU care preferably
• Ventilation care - pneumothorax, subcutaneous emphysema
• Speaking

19. Postoperative care
• Monitoring of vital signs
• Care of tracheostomy
• Chest physiotherapy, suctioning ,
• head up 30° to help venous drainage
• Chest X – ray, within 6 hours
• No tight bandage– airway impingement
• Bronchodilation, nebulisation
• Oxygen and analgesia

20. Patient’s limitations
• Swimming
• Cannot call aloud
• Climbing up the stairs,
• Strenuous work
• High altitude

21. Positioning
• The patient is laid in the supine position on the operating room table.
A shoulder roll is placed to allow for gentle neck extension. The bed is
rotated 180°

22. Monitoring & Follow-up
• Antibiotics are continued for at least 24 hours following laryngectomy.
Routine postoperative care, including vital signs, intake and output
monitoring, tracheostomy care, air humidification, and wound care is
started for all patients following surgery. Ventilator assistance and
bronchodilator therapy should also be considered in patients with co-
existent chronic obstructive pulmonary disease(COPD). Labs to assess
thyroid function and nutritional status should be ordered, especially
in irradiated patients. Tube feeds are initiated once bowel sounds are
present. Oral feeds are started after 1 week in nonirradiated patients.
Postradiation patients should wait 2-3 weeks before starting oral
feeds.