General anesthetic concerns of head and neck cancer surgery

1. General anesthetic concerns of head and neck cancer surgery Moderators: Prof.Chandralekha Dr.Darlong Presentors: Dr.Rakesh Dr.Prabhu.R www.anaesthesia.co.inanaesthesia.co.in@gmail.com

2. Surgeries • Tracheostomy • Diagnostic • Endoscopic examination • Therapeutic • Definitive oncological surgery • Reconstructive surgery

3. Anesthetic concerns • Problems related to age • Problems related to cancer • Securing an airway • Recovery

4. Age related problems • Generally older patients • Age related changes: Cardiac - CO ↓ 1% per year after 30 yrs. - Ability to  in response to stress is diminished. Pulmonary - PaO2 ↓ by 0.5 mm Hg per year after 20 yrs. - Rapid hypoxemia Hepatic - Drug clearance is impaired.

5. Contd.. Renal function - Cr CL ↓ by 1 ml/min/year after the age of 20 yrs. - S. Cr remains normal even in decreased clearance because of parallel ↓ in muscle mass. - High normal S. Cr→ underlying severe impairment in clearance . • Tobacco and alcohol use

6. Problems related to cancer Chemotherapy: Fortumorreduction • Toxicities: • Depends on specific agents, cumulative dosages, drug toxicity • Cardiac • Pulmonary • Hematological, bone marrow suppression • GI • Renal

7. Anthracyclin cardiotoxicity • Doxorubicin (adriamycin) • Acute: ECG- ST-T changes Reduction in ‘R’ wave • Chronic: Diastolic dysfunction→ CHF

8. Risk factors Cumulative dose: risk <1% for doses<300mg/m2 5%-10% for doses350to 450 mg/m2 30% for doses >550mg/m2 Schedule: greater risk with bolus less risk with continuous infusion less risk with dexrazoxone Mediastinal irradiation Cardiac disease: CAD, HTN, Valvular disease Age: young children, adults>70 Von Hoff et al: Risk factors for doxorubicin induced CHF. Ann Int Med 91:710,1979.

9. Contd.. • Cyclophosphamide: Hemorrhagic myocarditis • 5-FU: Coronary ischemia(1.6%) • Cytosine arabinose: Acute pericarditis • Paclitaxel: Asymptomatic bradycardia(30%) high incidence with cisplatin combination

10. Contd… Radiotherapy: • Airway fibrosis • Lung toxicity • Restrictive cardiomyopathy Metabolic abnormalities: • Tumor produced factors • Tumor cells destruction • Electrolyte imbalance

11. Preoperative evaluation • History: To determine the degree of compromise and risk. • Physical examination: “Focused” on CVS, Pulmonary and Airway. • Relevant laboratory data.

12. Pulmonary system • H/o pulmonary disease- higher incidence of perioperative complications. • Important predictor - Pre operative abnormal PFT. • Other predictors - obesity, - smoking - age>60

13. Contd.. • FEV1 < 2 L • Maximum breathing capacity < 50% of predicted. • PaCO2 >45 mm Hg. Tsi EM: Preoperative evaluation of pulmonary function: Validity, indications, and benefits. Am Rev Respir Dis 119:293-310,1979.

14. Contd.. Preoperative preparation of the patient with pulmonary disease can significantly reduce perioperative morbidity and mortality. Stein M, Cassar EL: Preoperative pulmonary evaluation and therapy for surgery patients. JAMA 211:787-792,1970.

15. Contd.. Reversible aspects of pulmonary disease: • Bronchospasm • Bronchitis with purulent sputum • Nutritional deficiency • Effects of cigarette smoking • Chronic hypoxemia • Corpulmonale • Tenacity of secretions

16. Contd.. • Educate - use of incentive spirometer - techniques of coughing and deep breathing - importance of early ambulation. • Preoperative bronchodilator therapy in COPD. • Smoking cessation PFT normalise by 8 wk. Reduction in COHb- 12hrs Warner MA, Divertie MB: Preop cessation of smoking and pulmonary complications in CABG patients. Anesthesiology 60:380-383,1984.

17. Contd.. Intraoperative: • Hydration • Humidified respiratory gases • Limit the use of respiratory depressants. • Prevent alveolar collapse - adequate Vt - avoid high FiO2

18. Contd.. Post operative: • Prevent alveolar collapse - Early ambulation - Chest physiotherapy

19. Cardio vascular system • According to ACC/AHA 2007 guidelines. • Head and neck surgery - intermediate risk • HTN, CAD. • Continue cardiac medications -β blockers, CCB • Fluid Mx: Rehydration Maintenance Replacement

20. Airway Information needed for evaluation: • H/o surgery in or near the airway. • H/o radiation in or near the airway • Previous anesthetic records documenting airway difficulty and methods utilised. • Physical examination • Radiological examinations • Laryngologic examinations- “latest” IDL

21. Difficult mask ventilation: - Age >55 yrs - Presence of beard - BMI>26 kg/m2 - Edentulousness - H/o snoring Langeron et al: prediction of difficult mask ventilation.Anesthesiology92:1229-1236,2000. - Masive jaw - Poor atlanto-occiptal extension Large tongue Pharyngeal pathology - Facial deformities - Facial dressings Recognition of difficulty

22. H/o difficult intubation Length of upper incissors Inter incisor length Overbite Shape of palate TMJ translation Mandibular space Cervical vertebral ROM TMD MMP Neck Difficult intubation Anethesiology 98:1269,2003.

23. Options • Tracheal intubation after induction of General Anesthesia. • Examination of the airway in the awake patient.- check DL • Tracheal intubation in the awake patient. FOB guided • Tracheostomy with local anesthesia

24. Difficult or failed intubation • Unanticipated difficult or failed intubation after induction of GA. • Options if MV adequate -Holinger anterior commissure laryngoscope -Fiberoptic guided laryngoscopy -Allow awakening

25. Holinger laryngoscape

26. Options if MV not adequate: -Follow ASA algorithm -Consider/attempt LMA -If not adequate follow the emergency pathway. • Cricothyrotomy Surgical Needle- for TTJV • Tracheostomy

27. Intra op airway management • Positioning of ETT Protect ala nasi from necrosis Direct tracheal operations need a change over to reinforced ETT. • Surgical field requirement Accordingly secure the ETT, circuit and connections • Tracheostomy

28. Extubation • Supraglottic, glottic edema- Post RND pts • Can be reduced by- Dexamethasone - Minimising movement of ETT - Elevation of head slightly • Lengthy/reconstructive procedures-keep intubated overnight. • Be ready with equipment to secure airway • Tube exchange catheter- reintubation guide - jet ventilation - both

29. JUVENILENASOPHRYNGEAL ANGIOFIBROMA Anesthetic concerns

30. JNA The juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular and histologically benign neoplasm. It causes severe recurrent epistaxis It Involves of endocranial structures . There is high incidence of recurrence. So JNA is clinically malignant.

31. Epidemiology • JNA accounts for 0.05% of all head and neck tumors. • 1:5,000-1:60,000 in otolaryngology patients. • Sex: JNA occurs exclusively in males. Females with JNA should undergo genetic testing. • Age: Onset is most commonly in the second decade; range is 7-19 years. JNA is rare in patients older than 25 years.

32. Etiology Hormonal dependency: - Most prevalent theory. - Occurrence exclusively in adolescent males - Alteration of the pituitary androgen- estrogen axis contributes to the pathogenesis of JNA.

33. Symptoms • Nasal obstruction (80-90%) - Most frequent symptom, especially in initial stages • Epistaxis (45-60%) - Mostly unilateral and recurrent; usually severe unprovoked epistaxis that necessitates medical attention. • Headache (25%) - Especially if paranasal sinuses are blocked • Facial swelling (10-18%)

34. Contd.. • Other symptoms - Unilateral rhinorrhea - anosmia - hyposmia - rhinolalia - deafness - otalgia - swelling of the palate -deformity of the cheek

35. Signs • Nasal mass (80%) • Orbital mass (15%) • Proptosis (10-15%) • Other signs Serous otitis- due to eustachian tube blockage Zygomatic swelling- trismus that denote spread of the tumor to the infratemporal fossa Vision impairment- due to optic nerve tenting (rare)

36. Pathology • Histopathology: Vascular component- Single layer of plump endothelial cells without the surrounding smooth muscle. lack of muscle- contributes to the tumor’s capacity for massive hemorrhage following minimal manipulation. It was recently suggested that JNA is not a true neoplasm but rather a vascular malformation

37. Point of origin

38. Growth pattern • Medial extension • Lateral extension • Intra cranial 20-30% • Orbital

42. Blood supply • External carotid artery (most often the internal maxillary artery and the ascending pharyngeal artery). • Blood vessels of the contralateral side. • Internal carotid system- in IC extension.

43. Natural history • Not well understood. • spontaneous regression (without therapy?) • Increase in fibrous elements of the tumour after 20 years of age. • Small residual tumours tend to involute.

44. Investigations • Hemogram, platelet count, prothrombin time, and partial thromboplastin time. • X-ray PNS - opacity in the nose and sinus areas. Skull lateral - mass inside the nasopharynx

45. CT scan clinch the diagnosis. reveals the extent of the lesion. helps in staging of the disease. • MRI reveals the precise extent of the mass. • Carotid angiogram feeding vessel

46. Staging Andrews staging classification:Stage I: Tumor limited to the nasal cavity Stage II: Tumor extension into the pterygopalatine fossa, or maxillay, sphenoid or ethmoid sinuses. Stage IIIa: Tumor extension into the orbit without intracranial involvement. Stage IIIb: Stage IIIa with extradural (parasellar) intracranial involvement Stage IVa: Intradural without cavernous sinus, pituitary, or optic chiasm involvement Stage IVb: Involvement of the cavernous sinus, pituitary, or optic chiasm

47. Treatment • Surgery: treatment modality of choice. Primary surgical cure rates for extracranial JNA are near 100%. Aproaches -transpalatal -transnasal (endoscopic) -lateral rhinotomy -midfacial degloving.

48. Irradiation- For surgically inaccessible intracranial extension or for recurrences. • Hormonal Estrogen Associated side effects

49. Anesthetic concerns • Risk of aspiration of blood during induction of anesthesia. • Major surgical bleeding, • Upper airway obstruction after extubation because of traumatic edema from the surgery

50. Anesthesia • Arrange blood and blood products • Premedication? • Two large bore IV cannulae • Induction -RSI? • Maintenance - O2+N2O+Iso+Vec • Monitoring -ECG,IBP,CVP, SpO2, capnography, temperature, and urine output