|Year : 2014 | Volume
| Issue : 3 | Page : 342-345
Management of difficult airway during laryngectomy and thyroidectomy
Sukhminder Jit Singh Bajwa
Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
|Date of Web Publication||18-Mar-2014|
Sukhminder Jit Singh Bajwa
House No-27-A, Ratan Nagar, Tripuri, Patiala, Punjab
Source of Support: None, Conflict of Interest: None
Laryngectomy is always a challenging surgery both from surgical and anaesthesiologist's perspective. The situation can get worse when such patients present with advanced laryngeal cancerrequire a definite surgical intervention along with thyroid gland removal. Apart from anesthetic difficulties in managing the deranged anatomy and pathophysiology, management of difficult airway during peri-operative period can be a huge challenging task. We are reporting a case of laryngeal carcinoma that was posted for laryngectomy and thyroidectomy as the thyroid gland was also invaded to a small extent. A difficult airway situation was anticipated as during indirect laryngoscopy it was observed that the glottic covering was occluded to a large extent by a soft tissue growth.
Keywords: Armored tube, difficult airway, laryngeal carcinoma, laryngectomy, thyroidectomy
|How to cite this article:|
Bajwa SS. Management of difficult airway during laryngectomy and thyroidectomy. Med J DY Patil Univ 2014;7:342-5
| Introduction|| |
In patients with laryngeal carcinoma, it is generally recommended that en-block resection of at least half of the thyroid gland on the side of the laryngeal tumor should be carried out. However, the complete resection of thyroid gland becomes mandatory if the tumor invades whole of the larynx.  Apart from anesthetic difficulties in managing the deranged anatomy and pathophysiology, management of difficult airway during peri-operative period can be a huge challenging task.Such radical dissection can pose numerous surgical and anesthetic challenges during peri-operative period.  Airway management is of prime importance in such patients both during intra-op and post-op period.  We are reporting a case posted for total thyroidectomy and laryngectomy where we anticipated and encountered a difficult airway pre-operatively.
| Case report|| |
A male patient of 63 years old and weighing 60kg reported to ENT outpatient department with hoarseness of voice, lump in the throat, slight breathing difficulty, occasional cough, and bad breath from the mouth for the last 6 months with a progressive increase in the intensity of the symptoms for the last 2 weeks. After availability of all the clinical and radiologic investigations, patient was diagnosed with squamous cell carcinoma of larynx. The prognostic aspects and possible complications associated with total laryngectomy and thyroidectomy were conveyed to the patient and his relatives and consent was taken for the radical surgery.
During pre-anesthetic check-up, it was revealed by the patient that he was a chronic smoker for the last 25 years. Pulmonary function tests revealed a slightly obstructive pattern but breath holding was greater than 20 s. Indirect laryngoscopy was carried out and a soft tissue growth was observed in the oral cavity which was occluding almost half of the glottic cavity. On clinical examination pulse rate was observed to be 74/min, blood pressure of 126/84mmHg, bilateral equal air entry on both sides of the chest with vesicular breathing and no abnormality detected on auscultation of heart. Rests of all his investigations were within normal limits and hemoglobin was estimated at 12gm%.
The patient was not given any sedative premedication in lieu of possible respiratory depression and obstruction. Only tabs ranitidine 150mg was administered overnight and on the morning of surgery. In the operation theater, patient was once again counseled and briefly described the procedure and told to co-operate. After securing an IV line with18G IV cannula, standard monitoring gadgets were attached,this included pulse rate, non-invasive blood pressure, pulse-oximetry, respiratory rate, ECG, and end-tidal carbon di-oxide. Gadgets for difficult airway were made ready and the difficult airway trolley was kept beside the operation table. An elective tracheostomy was done by ENT surgeons under sedation with dexmedetomidine infusion and trachea was secured with 8.0mm internal diameter (ID) cuffed tracheostomy tube.
Induction of anesthesia was carried out with propofol 120mg, butorphanol 1 mg, vecuronium 6mg, glycopyrrolate 0.2mg, and oxygen in air in the ratio of 50:50. After 3 min of intermittent positive pressure ventilation with Bains circuit mounted on tracheostomy tube, tracheostomy tube was taken out and an armored endotracheal tube 7.5mm ID was inserted through the tracheal stoma. [Figure 1] Direct laryngoscopy was also done to assess the intra-oral patency which revealed a complete obstruction of the glottic cavity with soft tissue growth. [Figure 2] Maintenance of anesthesia was achieved with oxygen, halothane, nitrous oxide, and vecuronium was given as per the requirements for muscular relaxation. Surgical intervention included total thyroidectomy and laryngectomy. Intra-operatively two units of bloods were transfused as blood loss during intra-op period was estimated at 800ml. Injection palonosetron 75μg was administered IV half an hour prior to anticipated completion of the surgical procedure. Surgical period was uneventful and lasted for 3 h. At the end of surgery prior to reversal of neuromuscular blockade with neostigmine (2.5mg) and glycopyrrolate (0.5mg), armored endotracheal tube was replaced with cuffed tracheostomy tube of 8mmID size. Patient was shifted to recovery and monitoring was done continuously and recorded at regular intervals. After 4 hpost-operatively, patient was shifted to high dependency unit.
|Figure 2: Soft tissue growth in the supraglottic region obstructing the glottic opening during direct laryngoscopy|
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| Discussion|| |
Difficult airway management is of prime concern among the anesthesia fraternity. Such challenges can be frequently encountered during neck surgeries such as thyroidectomy, parathyroidectomy, oral surgeries, and various syndromes involving head and neck. ,,,, [Figure 3]
Thyroidectomy and laryngectomy are challenging surgical procedures both in terms of surgeon's and anesthesiologist's perspective. The combined procedure in a same sitting definitely adds huge difficulties especially if such patients have co-morbidities or metabolic and metastatic changes due to carcinoma.  These procedures require careful handling of the patient and a meticulous planning for the surgical and anesthetic interventions. Total intravenous anesthesia (TIVA) with oral endotracheal intubation is the preferred technique of anesthesia administration.  But in the present case, it was revealed during indirect laryngoscopy that soft tissue growth in front of glottis can possibly pose airway challenges. The same was confirmed during the direct laryngoscopy after the airway was secured with elective tracheostomy. The complete occlusion of glottis after induction of anesthesia most probably occurred due to relaxation of pharyngeal and laryngeal muscles which maintained the patency of glottis during conscious spontaneous breathing.
|Figure 3: Showing the ease of thyroidecdtomy and laryngectomy with armored tracheal tube|
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Laryngeal carcinomas are one of the common cancers of neck region which are known for their notoriety in spreading to adjacent structures and compromising the breathing and deglutition functions. Invasion of thyroid gland by the laryngeal carcinoma has been reported in 1-30% of cases. ,, The controversies regarding partial or total laryngectomy and total or subtotal thyroidectomy have been a matter of debate, but in the present case it was decided to go for total laryngectomy and thyroidectomy considering the socio-economic status of the patient and clinical staging of the disease. , Certain risk factors are responsible for thyroid involvement in such carcinomas that may include but are not limited to fixed vocal cords, thyroid cartilage invasion, sub-glottic extension, and advanced stage of the disease. ,,
Oro-pharyngeal and neck lesions always pose airway difficulties during induction of anesthesia and intubation. Management includes formulations of different plans pre-operatively so as to decrease the morbidity and mortality associated with difficult airway management. In the present case, the difficult airway trolley was made ready for any anticipated and unanticipated airway obstruction.  The decision to perform elective tracheostomy was made after pre-anesthetic check-up in consultation with the ENT surgeon and it proved to be a correct decision later on. Such situations can be dealt by formulating multiple plans so as to timely switch over to the other if one fails. Intubation with RAE (Ring, Adair, Elwin) tube, submental intubation, retrograde intubation, intubation through LMA and many other methods can be employed in such a scenario but the choice is made depending upon various patient factors as well as availability of equipment and experience of anaesthesiologist. Though fibreoptic intubation remains the gold standard, its availability and clinical expertise in its use are two big limitations. The use of armored endotracheal tube was immensely helpful as with tracheostomy tube, breathing circuit was interfering in the surgical field while plain polyvinyl chloride (PVC) endotracheal tube can easily get kinked during surgical procedure. We did not have facilities for jet ventilation which could have been more useful in such circumstances.Moreover, the curvature of PVC tube would have made the surgery difficult as it is difficult to bend with causing kinking and obstruction.
Post-operatively these patients need extra vigilant care due to high incidence of potential complications associated with laryngectomy. The potential complications may include but are not limited to pain, nausea and vomiting, hemorrhage, laryngeal edema, recurrent and superior laryngeal nerve damage, tracheomalacia, hypothyroidism, pneumothorax and thyroid storm.
The maintenance of anesthesia with dexmedetomidine infusion was also immensely helpful as dexmedetomidine not only decreases the dose of anesthetics and sedatives but also prolong the post-operative analgesia.  The recovery profile of the patient was excellent and we did not observe any incidence of nausea and/or vomiting. Intra-operative administration of IV Palonosetron, 75μg can effectively provide an antiemetic action for a prolonged period. Incidence of shivering also gets reduced by peri-operative dexmedetomidine as was also observed in the present case, as we did not observe any incidence of shivering post-operatively. 
| Conclusion|| |
Thyroidectomy and laryngectomy in patients with laryngeal carcinoma can be smoothly and effectively carried out by resorting to current anesthetic technique. An elective tracheostomy prior to induction of anesthesia is immensely helpful in tiding over the difficult airway management challenges especially when the oral cavity is occupied by soft tissue growth in such carcinomas.
| References|| |
|1.||Elliott MS, Odell EW, Tysome JR, Connor SE, Siddiqui A, Jeannon JP, et al. Role of thyroidectomy in advanced laryngeal and pharyngolaryngeal carcinoma.Otolaryngol Head Neck Surg 2010;142:851-5. |
|2.||Gurunathan RK, Panda NK, Das A, Karuppiah S. Thyroid gland in carcinoma of the larynx and hypopharynx: Analysis of factors indicating thyroidectomy.J Otolaryngol Head Neck Surg 2008;37:435-9. |
|3.||Bajwa SS, Sehgal V. Anaesthesia and thyroid surgery: The never ending challenges.Indian J Endocr Metab 2011;17:228-34. |
|4.||Bajwa SS, Sehgal V. Anaesthetic management of primary hyperparathyroidism: A role rarely noticed and appreciated so far.Indian J Endocr Metab 2011;17:235-9. |
|5.||Mendelson AA, Al-Khatib TA, Julien M, Payne RJ, Black MJ, Hier MP. Thyroid gland management in total laryngectomy: Meta-analysis and surgical recommendations.Otolaryngol Head Neck Surg 2009;140:298-305. |
|6.||Bajwa SS, Kaur J, Singh A, Singh G. Post-burn facial contractures in pediatric patients: Challenging aspects of difficult airway management. Int J Health Allied Sci 2012;1:186-9. |
|7.||Bajwa SJ, Gupta S, Kaur J, Panda A, Bajwa SK, Singh A, et al. Anesthetic considerations and difficult airway management in a case of Noonan syndrome. Saudi J Anaesth 2011;5:345-7. |
|8.||Hilly O, Raz R, Vaisbuch Y, Strenov Y, Segal K, Koren R, et al. Thyroid gland involvement in advanced laryngeal cancer: Association with clinical and pathologic characteristics.Head Neck 2012;34:1586-90. |
|9.||Bajwa SJ, Bajwa SK, Kaur J. Comparison of two drug combinations in total intravenous anesthesia: Propofol-ketamine and propofol-fentanyl. Saudi J Anaesth 2010;4:72-9. |
|10.||Yuen AP, Wei WI, Lam KH. Thyroidectomy during laryngectomy for advanced laryngeal carcinoma-whole organ section study with long-term functional evaluation. Clin Otolaryngol Allied Sci 1995;20:145-9. |
|11.||Ceylan A, Koybasioglu A, Yilmaz M. Thyroid gland invasion in advanced laryngeal and hypopharyngeal carcinoma. Kulak Burun Bogaz Ihtis Derg 2004;13:9-14. |
|12.||Kim JW, Han GS, Byun SS, Lee DY, Cho BH, Kim YM.Management of thyroid gland invasion in laryngopharyngeal carcinoma. Auris Nasus Larynx 2008;35:209-12. |
|13.||Sparano A, Chernock R, Laccourreye O. Predictors of thyroid gland invasion in glottic squamous cell carcinoma. Laryngoscope 2005;115:1247-50. |
|14.||Amathieu R, Combes X, Abdi W, Housseini LE, Rezzoug A, Dinca A, et al. An algorithm for difficult airway management, modified for modern optical devices (Airtraq laryngoscope; LMA CTrach™): A 2-year prospective validation in patients for elective abdominal, gynecologic, and thyroid surgery. Anesthesiology2011;114:25-33. |
|15.||Bajwa SS, Kaur J, Singh A, Parmar SS, Singh G, Kulshrestha A, et al. Attenuation of pressor response and dose sparing of opioids and anaesthetics with pre-operative dexmedetomidine. Indian J Anaesth 2012;56:123-8. |
|16.||Bajwa SS, Bajwa SK, Kaur J, Sharma V, Singh A, Singh A, et al. Palonosetron: A novel approach to control postoperative nausea and vomiting in day care surgery. Saudi J Anaesth 2011;5:19-24. |
|17.||Bajwa SJ, Gupta S, Kaur J, Singh A, Parmar SS. Reduction in the incidence of shivering with perioperative dexmedetomidine: A randomized prospective study. J Anaesthesiol Clin Pharmacol 2012;28:86-91. |
[Figure 1], [Figure 2], [Figure 3]