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Year : 2014  |  Volume : 7  |  Issue : 3  |  Page : 266-271  

Anesthetic management and post-operative rehabilitation of laryngotracheal resection and reconstruction


Department of Anaesthesiology, Bharati Vidyapeeth University Medical College & Hospital, Wanleswadi, Sangli, Maharashtra, India

Date of Web Publication18-Mar-2014

Correspondence Address:
Jyotsna Satish Paranjpe
Department of Anaesthesiology, Bharati Vidyapeeth University Medical College & Hospital, Wanleswadi, Sangli, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.128945

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How to cite this article:
Paranjpe JS, Mane MV. Anesthetic management and post-operative rehabilitation of laryngotracheal resection and reconstruction. Med J DY Patil Univ 2014;7:266-71

How to cite this URL:
Paranjpe JS, Mane MV. Anesthetic management and post-operative rehabilitation of laryngotracheal resection and reconstruction. Med J DY Patil Univ [serial online] 2014 [cited 2021 Jan 19];7:266-71. Available from: https://www.mjdrdypu.org/text.asp?2014/7/3/266/128945

For many years, the treatment of obstructive lesions of the trachea and larynx was confined either to endoscopic dilatation and limited resection or to permanent tracheostomy. With a better understanding of respiratory physiology and improved techniques in surgery and anesthesia, a large proportion of these lesions can now be completely excised, the trachea successfully reanastomosed and larynx reconstructed [1] supplemented by perioperative chemotherapy and radiotherapy. [2] Recent research has focused on molecular biology to provide new treatment options and target therapy.

Head and neck squamous cell carcinoma is the sixth leading cancer by incidence world-wide. Males are affected more and it generally appears in the fifth, sixth and seventh decade of life. It is caused by tobacco and alcohol consumption and infection with the high-risk types of human papillomavirus. [3] When the carcinoma is localized to the larynx, the 5 years survival rate is 76% and the overall cure rate of laryngopharyngeal carcinoma is 57%. [1],[4]

To be able to avoid the devastating complications encountered during anesthesia for removal of the larynx; a thorough understanding of the anatomy, pathophysiology, surgical procedure, various techniques of ventilation and airway management is essential to obtain the maximum safety and quality care. In addition to facilitate surgery by providing an unobstructed and immobile operative field, anesthetists must provide oxygenation, carbon dioxide elimination, adequate anesthesia, rapid return of consciousness and airway reflexes after surgery. [2] Psychosocial factors of the patient include fear of choking, death and inability to communicate following tracheostomy. A hemithyroidectomy may be necessary in patients with transcartilaginous invasion of the thyroid. Post-operative thyroid studies and serum calcium levels should be obtained to determine the occurrence of hypothyroidism and/or hypoparathyroidism. Many patients return for multiple procedures. [4]

Benign or malignant laryngotracheal pathology causing obstruction can be managed in several ways including balloon dilatation, stenting, laser ablation and surgical resection. [5] Surgery of the larynx and trachea is a special endeavor where the airway is shared by the surgeon and the anesthesiologist. Anesthesia has been rendered less hazardous and has been simplified by developments in a variety of other airway-securing devices and techniques, including a laryngeal mask airway as a conduit for instrumentation [6] and ventilating bronchoscopes. With the developments in pharmacology, notably in total intravenous anesthetic agents and non-depolarizing neuromuscular blocking drugs, it is now possible to induce anesthesia without irritation of the airways, which may provoke coughing and any subsequent pressor response. [7] The principal anesthetic consideration is ventilation and oxygenation in the face of an open airway, which can be managed in different ways, including manual oxygen jet ventilation, superimposed high-frequency jet ventilation (SHFJV), [8] high frequency jet ventilation, intermittent positive pressure ventilation through a small oral or distal tracheal intubation, spontaneous ventilation, apneic oxygenation through a catheter and cardiopulmonary bypass. [2],[5]

Meticulous planning and communication between the anesthesia and surgical teams are mandatory for the safe and successful outcome of surgery for patients undergoing this procedure.


  Pre-operative Assessment Top


Patients with laryngeal tumors may present with dyspnea (may be on exertion or on rest, depending upon the severity of the stenosis), stridor (develops when the tracheal lumen is less than 5 mm in diameter), hoarseness, brassy cough, recurrent pneumonitis and cyanosis. There can be a deviated trachea or a reduced tracheal lumen size due to pre-operative radiation therapy hence X-ray neck in anteroposterior and lateral position is necessary. [9]

Fiberoptic bronchoscopy (FOB) remains the gold standard for diagnosis of laryngotracheal stenosis; however, it can be deferred until the time of definitive surgery, for the trauma of such an examination may produce edema and increase airway obstruction sufficiently to require hasty intervention. [1] Computerized tomography scan and magnetic resonance imaging with cross-sectional imaging help to define upper and lower limits of the lesions [2] and nasendoscopy provides advance warning of their appearance. [9] Precise information regarding site, size and extent of the lesion can be obtained from special radiologic studies, such as air tracheograms and laminograms. [1] Chest radiographs also give a good clue regarding air column in the trachea. Contrast media studies are avoided for fear of provoking complete obstruction. [1]

Pulmonary function is routinely studied pre-operatively, to measure the degree of respiratory obstruction and reveal any associated abnormalities in lung function. [1] Patients undergoing laryngotracheal reconstruction with uni- or bilateral neck dissection are exposed to prolonged anesthesia during which periods of ventilatory insufficiency are often unavoidable and throw considerable added load onto the heart. [1] Respiratory flow-volume loops can be helpful in the follow-up of these cases. [9]

However, in financially compromised situations, an experienced clinician can get a vast information about the overall status of the patient by simple examination of room air saturation on pulse oximeter alone.

Pre-existing lung or heart disease causing impairment severe enough to indicate a need for post-operative ventilatory assistance constitutes a relative contraindication to this form of surgery, for positive-pressure respiration with an inflatable cuff at the tracheal suture line may cause dehiscence; an extremely serious or lethal complication. [1]


  Pre-operative Management Top


Patients who develop carcinoma of the larynx are usually in the advanced age group and chronic bronchitis, emphysema, diabetes mellitus and cardiovascular diseases are common comorbidities. In addition, the tumor, because of its size and location, may reduce the cross-section of the airway. This narrowing of the air passages leads to tidal hypoxia with an accumulation of carbon dioxide. In patients with a severe laryngeal obstruction, blood gas studies have revealed respiratory acidosis. The accompanying hypoxia produces edema of the alveolar membrane and an increase in pulmonary secretions. The higher partial pressure of carbon dioxide in the alveoli renders the respiratory center less responsive to this normal stimulus and the main respiratory drive comes from the existing hypoxia through the carotid bodies. After tracheostomy such patients, when subjected to a high oxygen concentration, often become apneic. The effect is intensified if the respiratory center has been further depressed by anesthetic agents; therefore, it has been found advisable in patients with severe narrowing of the larynx to perform a tracheostomy for the relief of the tidal hypoxia and respiratory acidosis several days before the definitive operation. [10] Review of the literature suggests that when intubation replaced emergency tracheostomy for obstruction of the upper respiratory tract in children, the mortality fell from 30% to 0.8%. [4]

Elective tracheostomy as a part of the resection and reconstruction of the trachea is avoided whenever possible. Though this would minimize the problems of induction and maintenance, it lengthens the tracheal segment requiring resection and increases the complexity of the repair. Instead, an endotracheal tube (ETT) is used. The tip is placed above the lesion, for if adequate ventilation can be maintained up to the point of distal intubation. [1]

Where deterioration is progressive and edema of the tracheal mucosa is considered to be contributing, steroids are administered and diuresis is induced with a rapid-acting diuretic. With dehydration, respiratory obstruction frequently improves, allowing time for planned surgical intervention. Humidity is added routinely to the inspired air of all patients. By making secretions loose and easy to expel, chest physiotherapy is facilitated and the hazard of inspissated plugs forming and impacting at the narrowed site is minimized. [1] Pre-operative medication is designed to provide somnolence. With the quieter breathing of sedation, turbulence is diminished, airway resistance falls and ventilation often becomes easier. [1]

Alternatives of airway management after induction include the following: (1) Initial endotracheal intubation above the lesion followed by second intubation distal to the lesion after surgical opening of the trachea; the risk of inadequate ventilation caused by the severity of the stenosis would be present until the second intubation. Furthermore, the original ETT might traumatize the lesion and cause bleeding or dislodgment of tissue resulting in further airway obstruction. (2) Dilatation of the stenosis under direct vision with graduated rigid pediatric ventilating bronchoscopes and subsequent intubation of the lower trachea with a small ETT (size 5.0-6.0); the risk of tracheal wall perforation, of bleeding and of dislodging tumor particles would be present. (3) Jet ventilation via a catheter placed in the lower trachea; the risk of barotrauma as a result of a marginal effective tracheal diameter (≤4.5 mm) for the outflow of gasses during expiration would be present. (4) Intubation of the lower trachea with a 6.0 ETT through surgical tracheotomy. (5) Previous tracheostomy intubated with armored tube. [2],[9]

Pre-operative evidence of tumor-friability leads to the risk of traumatizing the tumor and causing dislodgment of at least fine tumor particles (e.g., cross-sectional diameter = 0.5- 1 mm) and/or bleeding during the passage of the 6.0 ETT into the lower trachea. The dislodged debris is not easily/timely removable through the FOB's working channel. Hence, an experienced endoscopist should be waiting standby with a rigid bronchoscope before oral intubation is attempted. [10]

In patients with large, fungating tumors that are not significantly obstructing the airway, insertion of oral ETT is preferred by many surgeons because there are no anesthesia attachments interfering with the operative field. Insertion of ETT should be performed under topical anesthesia. The mouth, nose and pharynx are sprayed with a topical anesthetic agent. Then a translaryngeal block is performed by injecting 2-3 cc of 2% lidocaine through the cricothyroid membrane. The ensuing cough produces adequate anesthesia of the larynx. [10] The problems with a small size tube are (1) high pressure is required for effective ventilation. (2) Length of the tube may be too small to negotiate the stenosis. (3) Frequent blockade of the tube due to secretions, blood or kinking may occur. (4) Risk of inadequate emptying of the lungs during exhalation phase. [9]

Over the last decades, different modalities of jet ventilation for laryngotracheal surgery have been developed. Initially, manually operated low-frequency jet techniques were used either from a supraglottic position with a metal nozzle attached to the endoscope or with special jet tubes or catheters positioned within the larynx. These were replaced by high-frequency jet techniques utilizing ventilators with mechanically or electronically operated valves. The use of jet techniques in patients with high-grade laryngeal or subglottic stenoses is still challenging for the anesthesiologist, but is controversially discussed in the published literature. [2] SHFJV consists of simultaneous supraglottic low- and infraglottic high-frequency jet ventilation. The technique is specifically useful for endoscopic laser ablation of the tumor. [8]

The only non-surgical option among these that does not require supraglottic access to the trachea is percutaneous transtracheal jet ventilation (PTJV). A more recent study describing the use transtracheal jet ventilation for 90 elective laryngeal surgical cases reported adequate ventilation with the minimal complications. [11] Advantages of PTJV in the management of the difficult airway include the following: Securing the airway before induction of general anesthesia; eliminating the need for laryngoscopy to secure the airway; providing an unobstructed view of the larynx and the potential to leave the catheter in place post-operatively in the event that the patient needs further respiratory support. Possible complications include barotrauma, kinking of the catheter and resulting soft-tissue emphysema, pneumomediastinum and pneumothorax. There have also been reports of infection at the site of the needle placement; however, these events are rare. PTJV has been shown to provide adequate ventilation for routine general surgery, laryngeal and oral surgery cases for up to 3.5 h. [11]

Ventilation with the total laryngeal bypass device (still unavailable in India) would be a useful alternative in the case of the inability to advance the 6.0 ETT through the stenotic tracheal segment. [1]


  Anesthetic Management Top


A laryngoscope, firm ETTs of various sizes, a pediatric bronchoscope [Figure 1] and tracheostomy equipment should be available at the bedside but are of no use when the lesion is in the lower half of the trachea. [1] Adequate ventilation during tracheal stenosis surgery can be very difficult in some cases. Therefore, a tier of flexible plans and a variety of ventilating means should be arranged before administering anesthesia. [9]

Light anesthesia is maintained with sevoflurane and oxygen. Relaxants are avoided, spontaneous respiration being preserved with assistance when necessary. Under these conditions, the larynx, pharynx and trachea are topically anesthetized and bronchoscopy is performed for the 1 st time to confirm the exact site, size and nature of the lesion. Following removal of the bronchoscope, the anesthetic gases are delivered through a large-bore rubber orotracheal tube placed in the trachea above the lesion. In cases of tracheomalacia, this tube can be passed atraumatically through the diseased segment. [1],[4]
Figure 1: Pediatric ventilating bronchoscope

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Current procedures, based on simple infusion devices, empiricism, simple non-invasive monitoring and experience, have proved more than adequate to safely manage cases of the kind. In a target-controlled TIVA, a combination of propofol, remifentanil and mivacurium is used. Anesthesia is maintained by continuing the remifentanil and propofol infusions at a rate that maintains normal pulse rate and blood pressure. A useful end-point to signal suitability for discharge to a recovery unit is the presence of all parts of the cough reflex: That is, deep non-stridulous inspiration, active closure of the glottis and an explosive expiration that is free of sounds of laryngeal spasm and that clears secretions. [4]

For high lesions, the trachea is explored through an anterior transverse cervical incision, with a median sternotomy if necessary. The segment distal to the obstruction is first dissected free, so that control of the airway can be obtained at any moment. Division of the trachea below the lesion completely relieves the obstruction, which has invariably been aggravated by manipulation of the trachea during its dissection. The distal tracheal segment is then intubated through the operating field with a sterile cuffed Tovell ETT. This is connected to the anesthetic machine by a Y-piece and two lengths of sterilized anesthetic hose [Figure 2]a. Thus, an anesthetic circuit, which bypasses the original ETT, is established. Constant attention is paid to the position of this second ETT, for its positioning is difficult and there is a tendency for it to advance into the right main stem bronchus during the dissection.
Figure 2: (a-c) Procedure for resection of high tracheal lesion

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Following excision of the affected segment, the trachea is reanastomosed with the distal ETT serving as the airway until its presence hampers further suturing of the cut ends [Figure 2]b. Its removal at this point allows the anastomosis to be continued and the operation is completed with the original orotracheal tube now advanced beyond the suture line and reconnected to the anesthesia machine [Figure 2]c. [1],[5]

Lesions of the lower trachea and carina are approached through a right thoracotomy, the general principles being unchanged. The ETT is placed above the lesion and ventilation is assisted to keep the right lung from collapsing till the trachea is dissected clear and transected distal to the lesion. Not infrequently, the distal tracheal stump is too short to hold an ETT. Under these circumstances the tube is advanced into the left main stem bronchus from the operating field. Ventilation and anesthesia are carried out entirely with the left lung while the diseased segment is excised. After dissection of the trachea, the right pulmonary artery is gently clamped to stop perfusion of the unventilated lung so that good arterial oxygenation can be maintained [Figure 3]a. During the latter part of the anastomosis [Figure 3]b the tube in the left main stem bronchus is replaced by the original ETT, which is directed down the bronchus [Figure 3]c. Later, it is retracted into the trachea ETT and right pulmonary artery is declamped to allow ventilation and perfusion of both lungs while the operation is completed. Where carinal resection is required, left lung ventilation is maintained with a second ETT entering the left main stem bronchus below the lesion while the affected segment is resected [Figure 4]a. The remains of the right main stem bronchus and trachea are then anastomosed end to end [Figure 4]b. The original ETT is then advanced beyond this suture line into the right main stem bronchus and perfusion and ventilation of the right lung resumed. An end-to-side anastomosis may then be performed between the left main stem bronchus and the side of the trachea [Figure 4]c On completion, the ETT is drawn above both suture lines and both lungs are ventilated with sevoflurane and oxygen while the operation is completed. [1],[4]

ETT inserted distal to laryngotracheal resection [Figure 5].
Figure 3: (a-c) Procedure for resection of lower tracheal lesions

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Figure 4: (a-c) Procedure for resection of carinal lesions

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Figure 5: ETT inserted distal to laryngotracheal resection

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Use of a double lumen ETT for tracheal surgeries is not popular since its insertion is difficult, it obstructs the view of surgeon and it cannot be mainta ined postoperatively.

In addition to the sudden acute falls in PaO 2 , which occur with one-lung ventilation, there is usually superimposed a slow and steady tendency for shunting to increase. This is believed due to atelectasis and results both from low tidal volume ventilation and the inevitable aspiration of blood. During the operation, a 5° head-down tilt and frequent tracheal suctioning keep aspiration to a minimum and regular deep breaths are administered whenever possible to reinflate any atelectatic alveoli. [1]

When the trachea is severed from the larynx and the ETT removed, there is a period of time during which the surgeon has to work on the permanent tracheostomy and the anesthesiologist cannot aid the patient's ventilation. [10] This is a dangerous point in the procedure, for if the ventilation (tidal volume) is depressed by excessive amounts of anesthetic agents or muscle relaxants, the patient will suffer from hypoxia. At the end of the operation, the patient should have his head elevated to aid the venous return from the head, which is compromised by the tight dressing around the neck and often by a resection of the internal jugular vein.

Intra-operatively the anesthetist must pay special attention to protect eyes, neck and teeth while optimizing surgical access in what may be a crowded area.


  Monitoring Top


Blood gases are closely monitored both during the operation and post-operatively to assess ventilation, oxygenation and acid-base status. An existence of a PaCO 2 above 70 mmHg and pH less than 7.2 are often associated with ventricular arrhythmias. [1] During bouts of acute obstruction, the PaCO 2 does not present an immediate threat to life, for with a complete apnea this rises only 3-5 mmHg/min. On the other hand, there occurs a sharp and steady fall in arterial oxygenation. During the breathing of high concentrations of oxygen, the A:aDO2 reflects the magnitude of right to left shunting. With a cardiac output that is stable, this gradient provides a sensitive and useful index of changes in shunting. [1] When the distal segment of the trachea is short, the ETT, which enters through the wound cannot be reliably fixed; slight movements of either the tube or the neck result in right main stem bronchus intubation. This is usually detected by a fall in compliance and unequal movement of the chest. [1]


  Post-operative Care Top


These patients require intensive care unitcare with specialized staff to manage sedation and paralysis, mechanical ventilation, steroids and infection, feeding, chest physiotherapy. The patients are paralyzed and sedated for 48 h and then gradually extubated over 72 h. [9] Their necks are maintained in a position of flexion for approximately 1 week to minimize tension on the tracheal suture line. Oxygen is delivered by mask to achieve a PaO 2 of 75-100 mmHg and added humidity and chest physiotherapy are administered to all patients in an attempt to keep secretions loose and the chest clear. Close surveillance of the airway and the regular performance of pulmonary function tests provide exact and detailed information of the patient's course. [1]


  Rehabilitation after Total Laryngectomy (TL) Top


After laryngectomy since there is loss of speech, dysphagia, change in the pattern of respiration and olfaction; there is a profound alteration in the life-style of the patient. [4] Learning to live with cancer as more of a chronic disease can be hard and very stressful, for which the patient needs psychological and physiological rehabilitation. Patients with permanent tracheostomy or gastrostomy need to be trained for stoma care. [2]

There are three basic options for voice restoration after TL (1) artificial larynx speech (2) esophageal speech (3) tracheoesophageal speech. Selection of a method is best made keeping in mind the patients communicative needs, physical and mental status and personal preference. [10]

Esophageal speech: Proficiency in esophageal speech requires several months of speech therapy. The speech is in short bursts as the bellow effect of the lungs is lost. It is cost effective, hands free and sounding is natural [Table 1]. [12]
Table 1: Complications[10]

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Electrolarynx/artificial larynx: An external mechanical sound source is substituted for the larynx. Two general types of electrolarynges are available; the neck type is more frequently used than the intraoral type. A third type of electrolarynx uses an electromyograph (EMG) transducer to activate a sound source for hands-free use. In this case, though the voice restoration after surgery is immediate, mechanical quality of speech and high cost are prohibitive. [12]

Tracheoesophageal speech: An additional surgery is required for the creation of an opening between the trachea and esophagus. A one-way valve is introduced through this stoma, which allows lung air to pass into the esophagus without food and liquids passing into the trachea. It permits early restoration of natural phonation, but aspiration of liquids leaking through a malfunctioning valve is a major disadvantage of it. [12]

 
  References Top

1.Geffin B, Bland J, Grillo HC. Anesthetic management of tracheal resection and reconstruction. Anesth Analg 1969;48:884-90.  Back to cited text no. 1
[PUBMED]    
2.English J, Norris A, Bedforth N. Anaesthesia for airway surgery. Contin Educ Anaesth Crit Care Pain 2006;6:28-31.  Back to cited text no. 2
    
3.Rousseau A, Badoual C. Head and neck: Squamous cell carcinoma: An overview. Atlas Genet Cytogenet Oncol Haematol 2011;24:4170-6.  Back to cited text no. 3
    
4.Healy DW, Bradford CR. Anesthesia for neck dissection and laryngectomy. Anesthesia for Otolaryngologic Surgery. Chapter 15. Cambridge: Cambridge University Press; 2012. p. 143-50.  Back to cited text no. 4
    
5.Pinsonneault C, Fortier J, Donati F. Tracheal resection and reconstruction. Can J Anaesth 1999;46:439-55.  Back to cited text no. 5
    
6.Bouaggad A, Bennani F, Al Harrar R, Bouderka MA, Harti A. Anesthesia for a patient with tracheal tumor using laryngeal mask airway. Anesth Analg 2006;103:258-9.  Back to cited text no. 6
    
7.Conacher ID. Anaesthesia and tracheobronchial stenting for central airway obstruction in adults. Br J Anaesth 2003;90:367-74.  Back to cited text no. 7
[PUBMED]    
8.Rezaie-Majd A, Bigenzahn W, Denk DM, Burian M, Kornfehl J, Grasl MCh, et al. Superimposed high-frequency jet ventilation (SHFJV) for endoscopic laryngotracheal surgery in more than 1500 patients. Br J Anaesth 2006;96:650-9.  Back to cited text no. 8
    
9.Ahmed S, Janjua S. Tracheal stenosis surgery; Airway management. Prof Med J 2010;17:638-42.  Back to cited text no. 9
    
10.Boyan CP, Howland WS. Management of anesthesia for laryngectomies. Anesth Analg 1959;38:150-4.  Back to cited text no. 10
[PUBMED]    
11.Gulleth Y, Spiro J. Percutaneous transtracheal jet ventilation in head and neck surgery. Arch Otolaryngol Head Neck Surg 2005;131:886-90.  Back to cited text no. 11
    
12.Mendenhall WM, Morris CG, Stringer SP, Amdur RJ, Hinerman RW, Villaret DB, et al. Voice rehabilitation after total laryngectomy and postoperative radiation therapy. J Clin Oncol 2002;20:2500-5.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]


This article has been cited by
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Usha Kumary R,Sukanya Prince Mary A J,Sharath Padmanabhan,Lakshmi Micka
Journal of Evolution of Medical and Dental Sciences. 2016; 5(41): 2560
[Pubmed] | [DOI]



 

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