Laryngectomy

Laryngectomy

Anesthesia type	General
Airway	ETT
Lines and access	PIV, +/-Large bore IV, +/-Arterial Line, +/- Central Line
Monitors	Standard, +/- ABP, +/- CVP
Primary anesthetic considerations
Preoperative	Multiple comorbidities, Securing airway
Intraoperative	Possible re-intubation by surgeon, vagal response (bradycardia), avoid hypertension, pneumothorax
Postoperative	Hypertension, tachycardia, hypoventilation, pain
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Laryngectomy refers to the removal of all or part of the larynx. It is almost exclusively performed due to laryngeal tumor, primarily squamous cell carcinoma secondary to smoking, alcohol, and/or HPV. Laryngectomy may be performed as a primary procedure or after radiation or chemoradiation. The procedure often involves neck dissection due to local tumor invasion and/or lymph node dissection.

• Partial laryngectomy involves removing some but not all of the laryngeal structures (see Procedure Variants). Temporary tracheotomy is often used.
• Total laryngectomy involves resection of entire larynx; may involve neck dissection. Remaining trachea is sutured to the skin for tracheostoma (permanent).

Overview

Indications

• Cancer of larynx
• Intractable aspiration events unresponsive to other management techniques

Surgical procedure

The surgical procedure is generally 2-4 hours but may be as long as 8 hours if neck dissection is included. Estimated blood loss is 50-500 mL; transfusion generally not indicated.

• Expose the neck musculature, generally with a U-shaped incision on anterior neck.
• +/- Neck dissection, lymph node removal
• Skeletonization of the larynx
• Horizontal cut of trachea, surgeon places sterile endotracheal tube in lower tracheal stump.
• Stoma creation, closure

Preoperative management

Patient evaluation

Laryngectomy patients are often tobacco users, alcohol users, and/or elderly. These patients benefit from evaluation in the pre-operative anesthesia clinic.

System	Considerations
Airway	May be compromised due to malignancy; possible history of neck surgery, trauma, or XRT leading to decreased tissue compliance, decreased neck range of motion, vocal cord dysfunction, and small/altered mouth opening. Possible history of difficult intubation; may have previously proven airway, consider subsequent changes to airway due to neoplastic process. Airway tumors are often friable and prone to bleeding; gentle airway manipulation is indicated.
Neurologic	In patients with a history of ETOH abuse, symptoms of alcohol withdrawal should be controlled before surgery. Anticipate increased anesthetic requirements.
Cardiovascular	Often have an increased incidence of CAD, HTN. Careful assessment of cardiac risk factors and functional status. Listen for carotid bruits. Note any symptoms of compromised cerebral circulation. HTN should be controlled preop because uncontrolled HTN carries the additional risk of exaggerated hemodynamic responses postop secondary to surgical denervation of the carotid sinus.
Pulmonary	Often have COPD, chronic bronchitis. May be hypoxemic at baseline +/- hypercarbic. Consider arterial blood gases if large A-a gradient is suspected.
Gastrointestinal	Patients may have poor nutritional status secondary to alcohol abuse and/or difficulty eating. May have significant electrolyte abnormalities secondary to malnutrition (hypokalemia, hypomagnesemia). In those with history of alcohol abuse, may have liver disease and cirrhosis.
Hematologic	May have anemia or be coagulopathic in the setting of malignancy or other chronic disease. May be hypercoagulable due to malignancy.
Renal	Patients may have chronic renal insufficiency.
Endocrine	May be diabetic
Other	Chronic nicotine and alcohol use can induce cytochrome p450 leading to increased opioid and NMB requirements.

Labs and studies

• Pulmonary evaluation: CXR, preop ABG in patients with significant pulmonary disease. Flow-volume loops may be of utility for patients with partial airway obstruction. Consider nasal airway endoscopy, particularly if changes to respiratory status have occurred since last endoscopic exam.
• Cardiac evaluation: Consider carotid ultrasound, cardiac stress test and imaging studies (e.g. CT, MRI of head and neck) based on H&P. If unable to evaluate functional status, patient should have a stress test.
• CBC, coagulation studies
• LFTs, electrolytes, albumin, BUN, creatinine.

Patient preparation and premedication

• Avoid premedication in patients with symptoms of partial airway obstruction.
• Ability to secure the airway is of utmost consideration. Discuss securing airway with surgeon as well as back-up plans. Low threshold for awake intubation especially for patients with stridor. May require treatment with bronchodilators before induction.

Regional and neuraxial techniques

Generally not performed but could consider deep and superficial cervical plexus blocks as well as cervical epidural.

Intraoperative management

Monitoring and access

• Monitors: standard, +/- art line (do not place in operative arm if radial forearm flap is planned), +/- CVP (check with surgeon regarding placement), foley (preferably with temperature monitoring.
• Access: Generally one 16 or 18 gauge IV, although two large bore IVs should be considered in cases with increased possibility of hemorrhage.
• If head-up tilt is used, arterial blood pressure transducer should be at the level of the brain (external auditory meatus)

Induction and airway management

• Preoxygenation should be prioritized to maximize the apneic timeframe. Consider trans-nasal high flow rapid insufflation ventilatory exchange.
• May consider DL or FOI with inhalational induction; consider sliding Jackson scope, equipment for FOI, awake intubation, or retrograde intubation (although likely difficult in the setting of airway tumors)
  • Most tumors are submucosal. In those with exophytic growth, direct visualization is necessary to decrease the possibility of seeding the lower airway and/or bleeding.
  • May use specialized nerve integrity monitor endotracheal tube.
• If difficult airway is suspected, the surgeon and tracheostomy kit should be in the room. Consider difficulty performing tracheostomy in patients with previous head and neck surgeries and/or radiation.
  • In patients with severely compromised airways, consider awake tracheostomy with local anesthesia.
• Secure tube well due to patient positioning (see Positioning).

Positioning

• Supine, head extended.
• Head often 90 or 180 degrees from anesthesia machine; neck often rotated away from surgeon, can lead to brachial plexus stretch injury, particularly for radical free flap due to the positioning of the arm.
• Pad pressure points; careful taping of eyes (will be under drapes and difficult to access).

Maintenance and surgical considerations

• If neck is dissected, avoid paralysis until after marginal mandibular nerve and XI are identified.
• Maintaining SBP <100 mmHg may reduce bleeding in the surgical field particularly since the neck is highly vascular. However, consider that many of these patients are chronically hypertensive at baseline and SBP <100 may lead to cerebral ischemia.
• Coughing and bucking should be avoided as these may contribute to bleeding or disrupt delicate sutures.
  • Use of opioids reduces MAC while blunting tracheal responses to stimulation.
• When tracheostomy is created during the procedure, the surgeon will place sterile, reinforced tracheostomy tube. Proper placement should be confirmed by presence of ETCO2, bilateral breath sounds, and normal airway compliance. FiO2 should be at least 50% as surgeon may temporarily remove ETT as they are placing sutures. Monitor for mainstem intubation. Communication is of utmost importance during this part of procedure. Music should be off and conversations minimized.
  • If electrocautery will be used during surgical dissection of the trachea, limit FiO2 to 30% or less.
• Lengthy surgeries may result in the saturation of fatty tissue with anesthetic agents leading to prolonged wake up times.

Potential Intra-Op Complications

• Bradycardia from vagus nerve or carotid bifurcation stimulation, generally self-resolves with withdrawal of stimulation; can give IV atropine. Can also apply topical or locally injected anesthetics.
• In neck dissection, venous air embolism is a rare complication.
• There have also been reports of prolonged QT interval, especially during right neck dissection which may lead to ventricular arrhythmias or cardiac arrest.
• Hypoparathyroidism can result in extensive neck dissection if parathyroids are removed.

Emergence

• If tracheostoma is created (i.e. total laryngectomy), intubation is only possible from stoma; it is NOT possible to oro- or nasotracheally intubate the patient.
• In patients with partial laryngectomy, discuss with the surgeon whether the patient may be oro- or nasotracheally intubated post-surgically.
• If tracheostomy was not performed, consider staged extubation over airway exchange catheter.
• Consider IV labetalol before awakening to prevent rebound hypertension (possibly secondary to denervation of carotid sinus).

Postoperative management

Disposition

Inpatient admission for 5-10 days; may require ICU care for tracheostomy or extensive reconstruction, free flaps.

Pain management

Pain score is generally 4-8 (higher pain score with laryngectomy plus neck dissection). PCA and parenteral opiates are most commonly employed.

Potential complications

• Hypertension and tachycardia: Particularly in bilateral neck dissection secondary to carotid sinus/body denervation; treat aggressively with medication (e.g. labetalol).
• Loss of hypoxic drive: Due to denervation of carotid sinuses and bodies particularly after bilateral neck dissection.
• Nerve injury: facial, recurrent laryngeal, phrenic. Phrenic may lead to respiratory distress due to diaphragm paralysis.
• Pneumothorax: Can occur with lower neck dissection.
• Agitation: May occur secondary to restrictive neck dressings; may also be due to hematoma. Reestablish airway if necessary.

Procedure variants

• Partial laryngectomy
  • Vertical partial laryngectomy: removal of affected true and false vocal cords and up to one third of contralateral folds. A temporary tracheostomy is placed.
  • Supraglottic laryngectomy: removal of laryngeal structures superior to true vocal cords. May include base of tongue. A temporary tracheostomy is placed.
  • Supracricoid laryngectomy: removal of larynx from top of cricoid ring to hyoid bone with preservation of at least one arytenoid. May involve removal of epiglottis. Requires temporary tracheostomy.
• Total laryngectomy
  • Transesophageal puncture: May be performed with total laryngectomy in order to place voicing prosthesis. A tract/fistula is placed between the trachea and esophagus. Some surgeons may use a red rubber catheter through the fistula to feed the patient instead of NG or gastrostomy tube. The red rubber is later switched to the prosthesis when the patient is able to resume oral intake. The red rubber may protrude from the stoma, so care should be taken to not dislodge it.
  • Total laryngectomy may include hypopharynx or oropharynx so patient may need flap reconstruction. May use pectoralis major myocutaneous flap or radical free flap. If esophagus is resected, jejunal free flap or gastric pull-up may be necessary.

References

Butterworth, J. F. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education.

Charters, P., Ahmad, I., Patel, A., & Russell, S. (2016). Anaesthesia for head and neck surgery: United Kingdom National Multidisciplinary Guidelines. The Journal of Laryngology & Otology, 130(S2), S23–S27. https://doi.org/10.1017/s0022215116000384

Hoppe, F., Theissing, J., Rettinger, G., Werner, J. A., & Rudack, C. (2011). ENT—Head and Neck Surgery: Essential Procedures /. Georg Thieme Verlag.

Jaffe, R. A., Schmiesing, C. A., & Golianu, B. (2014). Anesthesiologist’s manual of surgical procedures. Wolters Kluwer Health.

Prout, J., Jones, T., & Martin, D. (2014). Advanced training in anaesthesia : the essential curriculum. Oxford University Press.