Anaesthesia for Oncological ENT Surgeries

1. Anaesthesia for Oncological ENT Surgeries Moderators: Prof Chandralekha Dr V Darlong Presenters: Rakesh Garg Prabhu www.anaesthesia.co.inanaesthesia.co.in@gmail.com

2. Head and Neck Surgery • Laryngectomy • Hemimandibulectomy • Maxillectomy • Angiofibroma • Glossectomy • Pharyngectomy • Radical neck dissection

3. Cont… • Tracheostomy • Diagnostic • Endoscopic examination • Therapeutic • Definitive oncological surgery • Reconstructive surgery

9. Conclusion • Duration of anesthesia and ASA class- significant predictors of major complications • Comorbidity - established important factor • 3 significant risk factors: • site of primary tumor • adjunctive treatment • low hemoglobin

15. Perioperative Concerns • Prolonged surgery and its complications • Blood loss and its conservation strategies • Sharing of airway • Surgery related implications

16. Indicators of Difficult Airway • Changes in the voice • H/o dyspnoea, dysphagia or inability to handle oro-nasal secretions • Radiation to head and neck • H/o difficult airway • Previous head and neck surgery • Tumors and edema of pharynx and hypopharynx

17. Airway examination • Examination of the oral cavity-site, size and friability of the tumor- indirect laryngoscopy • Mouth opening • Mallampati grading • Mandibular space • Assessment of sniffing position. • Adequacy of mask placement.

18. Investigations • Hematological • Biochemical • Chest X-ray • ECG • STN X ray • CT • MRI • Laryngoscopy / endoscopy • PFT / FV loops

19. Premedication • Cancer – emotional and psychological state • Cautious premedication • Avoid sedative drugs • Analgesics

20. Anaesthetic Management Selecting the appropriate anesthetic technique compatible with the surgical procedure

25. LMA in ASA DA algorithm

26. 260 patients review

29. Airway Management • Awake Oral FOB • Awake Nasotracheal intubation • Inhalational induction • Tracheostomy under LA • Acute airway compromise - Transtracheal Jet Ventilation • Tracheal extubation and Jet Stylet • Retrograde Tracheal Intubation - awake patient

30. Cont… • ETT and connectors • nonkinking and properly secured • Breathing circuit - secured to patient’s head • Constant vigilance -prevent the breathing circuit from pulling downward on the tube’s adapter

31. Cont… The lengthy surgical procedure near the airway and bulky flap reconstruction may cause oedema around the airway making extubation even more challenging than the intubation

32. Cont… • Nerve blocks – contraindicated- tumour • Coughing and straining :awake intubation - trauma and bleeding • Pectoralis major flap tunnelled through the neck- risk of airway obstruction (bulk) than does a free flap. • Postoperative local oedema

33. Monitoring • Routine • Capnography • Invasive monitoring - arterial BP and CVP • Arterial line and cannulas • Central line - antecubital, subclavian or femoral • Two large bore cannulas • Urinary catheterization • Temperature monitoring

39. Intraoperative Tracheostomy • 100% oxygen • Suction • Tube pulled just above the tracheal incision • TT inserted • Ventilations checked • Observe –breath sounds, capnography, airway pressure, compliance

40. Extubation Extubation • degree of edema and • upper airway distortion produced by the surgery • Lengthy procedure, free flap reconstruction- intubated, sedated overnight in the ICU • Others extubated in the OT or PACU when they are fully awake Equipment for securing the airway • readily available

41. Intraoperative and Postoperative Complications • VAE • Carotid sinus manipulation • Stellate Ganglion injury • Positioning- neck torsion • Airway compromise – edema, hematoma

42. Maxilla Cancer Concerns: • Difficult Airway • Bleeding • CSF leak/ pneumocephalus • Infection • Visual impairment • Enopthalmos

43. Mandible cancer Concerns: • Tumour • Primary • Infiltration from adjoining structures • Resection – segmental/hemimandibulectomy • Osteocutaneous flap/plates

44. Reconstructive surgery Flaps: • Skin grafting • Local flaps • Pedical fasciocutaneous flap • Musculocutaneous flap • Osteocutaneous flap • Evaluated invidualized

45. Intraoperative Considerations • Avoid cannula/monitoring devices at flap donor sites • Secure monitoring/airway devices – change of position • Blood loss • Hemodynamics • Hypotension: • Avoid vasoconstrictors • Decrease inhaltional agents • Fluids • Avoid shivering/pain - vasoconstriction

46. Laryngeal cancer Conservative laryngeal procedures  total laryngectomy • Laser surgery • Vertical hemilaryngectomy • Supraglottic laryngectomy • Supracricoid partial laryngectomy • tracheostomy

47. Direct LaryngoscopyMicrolaryngoscopyLaser LaryngoscopyMicrolaryngeal Endoscopic Surgery Goals: • Dry immobile field • Securing Airway and protection • Oxygenation and ventilation • Anaesthetic technique – short, rapid and full recovery • Hemodynamic stability

48. Anaesthesia • No airway compromise – premedication, standard induction • Antisialagogue, sedation • Vigilant – inadveretent extubation, kinking, disconnection • Cardiac monitoring • Induction and maintenance – short acting agents, muscle relaxant, narcotics, beta blockers

49. Cont… • Posterior commissure – MLS tube • Protection of eyes/teeth • Anaesthesia machine and monitors – side of patient, head end free

50. Other Ventilatory Strategies • Supraglottic jet ventilation • Subglottic jet ventilation • Transtracheal jet ventilation • Free access to expiration • Intravenous anaesthesia, unpredicted inhalation • Pneumothorax, pneumomediatinum, submucosal emphysema • Blood, debris – tracheal ingress • Postoperative CxR • Apneic ventilation • Tracheostomy