Authors: James McAvoy, MD; Tyler Ewing, MD; Vladimir Nekhendzy, MD Institution: Stanford Department of Anesthesiology, Perioperative and Pain Medicine Background: Airway management of patients with head and neck cancer... [ view full abstract ]
Authors: James McAvoy, MD; Tyler Ewing, MD; Vladimir Nekhendzy, MD
Institution: Stanford Department of Anesthesiology, Perioperative and Pain Medicine
Background: Airway management of patients with head and neck cancer presents significant challenges and requires carefully devised strategies. Patients with supraglottic and glottic tumors or history of radiation therapy require the longest intubation times and represent the highest risk for adverse outcomes. In NAP4, airway management was considered poor in nearly 30% of these cases.
Preoperative endoscopic airway examination (PEAE) is a powerful tool that provides precise information about upper airway and laryngeal anatomy to formulate appropriate airway management strategies. It is the only technique that allows the anesthesiologist to visualize the degree of obstruction and tumor mobility directly. Even in urgent situations, PEAE may help with anticipation and planning for a difficult airway.
Case Description: A 78 year-old woman with recurrent T2N2 squamous cell carcinoma of the right neck, status-post modified radical neck dissection, presented for direct laryngoscopy and biopsy of the supraglottic lesion. A nasal endoscopy in ENT clinic 2 weeks prior to surgery revealed a new 3.5 cm right superior pyriform sinus mass involving the right aryepiglottic fold and the base of the epiglottis. Given the rapid presentation of the recurrence and its proximity to the endolarynx, the anesthesia team performed a PEAE to facilitate airway management planning. The PEAE revealed a large right pyriform sinus mass extending into valecula and significantly displacing the epiglottis and laryngeal inlet (Figure 3). There was no ball valve phenomenon, and no glottic/subglottic obstruction.
Given significant anatomical distortion, a difficult laryngeal view, and a concern for traumatizing the tumor during endotracheal tube (ETT) advancement off the flexible fiberoptic scope (FFS), the plan was formulated for an asleep, combined video laryngoscopy (VL) - FFS intubation. After induction of anesthesia, the Pentax Airway Scope (AWS) was inserted under the epiglottis in a Miller blade-type fashion, and provided a clear laryngeal view. FSS was then placed through the ETT positioned inside the channel of AWS, and maneuvered through the glottic opening into patient’s trachea using AWS enlarged laryngeal view as a target. Atraumatic ETT (6.0 mm ID) advancement was observed continuously on AWS and FFS video screen. The remainder of the anesthesia and surgical procedure proceeded without complications, and the patient was extubated uneventfully at the end of the case, fully awake.
Discussion: The presented case demonstrates the essential role of PEAE in helping to formulate optimal airway management strategies in patients with anticipated difficult airway. PEAE findings in this patient with a significant vallecular tumor intrusion helped to choose the appropriate VL technique to minimize tumor disturbance.
Furthermore, the combined VL-FFI provided unique advantages for complex airway management, facilitating FFS manipulation and allowing for continuous observation of the whole intubation procedure and atraumatic ETT advancement.
While the combined video techniques will likely continue to play bigger role in complex airway management of head and neck patients, the PEAE should become an integral part of the anesthesiologist’s armamentarium in anticipated difficult airways.
