The majority of oral cancer patients in India are diagnosed at an advanced stage (stage 3 and 4) requiring prolonged surgery with myocutaneous flap reconstruction . General anaesthesia for surgery in these patients is one of the most challenging tasks for an anaesthetist. There is potential for difficult airway due to limited head and neck mobility and position, limited mouth opening, limited upper airway open space resulting from tumour, oedema or previous surgery, distorted airway anatomy by tumour expansion or previous surgery and fixation of the tissue of the oral cavity, pharynx or larynx by tumours, surgical scar or radiation fibrosis [2,3]. We prefer nasotracheal intubation and use tracheostomy very selectively for management of airway in these patients. This retrospective study examines the airway management and merits of nasotracheal intubation over tracheostomy in 260 patients with oral cancer undergoing surgery.
A retrospective study was undertaken of 260 patients undergoing surgery for oral cancer (tongue, alveolobuccal mucosa, floor of mouth and retromolar tumours) from October 1999 to September 2003 at The Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi. Medical records of these patients were reviewed for perioperative anaesthetic management. Pre-anaesthetic records were reviewed for co-morbid conditions and assessment for difficult airway. Intraoperative records were reviewed for choice of induction, techniques of airway management, any intraoperative complications and number of tracheostomies. In the postoperative records time of extubation, emergency tracheostomies and postoperative complications were recorded.
Details of the 260 patients are shown in Table 1. Eighteen patients had previous surgery for oral cancer and were scheduled for flap reconstruction, recurrence or other complications. In 28 cases neck movement was restricted as judged subjectively by the anaesthetist. Decreased mouth opening was found in 50% of all patients because of a large growth or fixation of tissues of head and neck, oral cavity, pharynx, or larynx by tumour, or radiation fibrosis. Pre-existing medical disorders are shown in Table 1. Fibreoptic nasotracheal intubations (53 patients) were performed under spontaneous ventilation in patients who had a previous history of oral cancer surgery (18 patients) and in patients in whom mouth opening proved to be inadequate for direct laryngoscopy (35 patients) (Table 2). In none of our patients was in any sign of upper airway obstruction present preoperatively. In all remaining patients a neuromuscular blocking agent was administered after checking for adequate positive pressure ventilation with either a face mask or a nasopharyngeal airway. In all cases with direct laryngoscopic grade 3 and 4, and where a single attempt at nasotracheal intubation could not be achieved, fibreoptic nasotracheal intubation was performed (Table 2). In 20 cases where flap reconstruction and/or bilateral neck dissection was not required and patients demonstrated good protective reflexes, the trachea was extubated in the immediate postoperative period. In all other cases extubation was undertaken next morning in the surgical intensive care unit (ICU) when all the criteria of extubation were present. The mean length of nasotracheal intubation was 23 h including operating time (range 5-52 h) (Table 2). In none of the cases was elective tracheostomy under local anaesthesia performed before surgery for the maintenance of the airway for anaesthesia. Elective planned tracheostomy was performed in 17 cases according to the indication at the end of the surgery.
Three patients remained intubated for 24-48 h as there was high suspicion of airway obstruction following extubations because of large pectoralis major flaps. These three patients had a tracheostomy because of increased oropharyngeal and laryngeal oedema 24-48 h after surgery. A total of three emergency tracheostomies were performed and in two out of three cases the emergency tracheostomy was performed when respiratory distress occurred within 24 h after extubation due to upper airway obstruction. In one case emergency tracheostomy was performed on the 5th postoperative day when the patient developed upper airway obstruction and severe respiratory infection requiring long-term ventilation of more than 2 weeks. Except for this patient, no other patients developed severe respiratory infection requiring mechanical ventilatory support in the immediate or early postoperative period. One patient with a history of ischaemic heart disease showed evidence of fresh ischaemic episode in the postoperative period. One patient with a history of asthma developed severe acute bronchospasm in the immediate postoperative period requiring intensive treatment. In one case paroxysmal supraventricular tachycardia and in two patients ventricular premature beats requiring treatment developed in the immediate postoperative period.
There was no anaesthesia or airway-related mortality during the perioperative period. The median duration of hospital stay after surgery was 12 days (range 6-44).
The presence of oral cancer together with associated anatomical changes make airway management a difficult task to accomplish . Prior surgery for oral cancer or radiotherapy further makes mask ventilation and tracheal intubation difficult due to loss of anatomical landmarks and fibrosis. The lengthy surgical procedure near the airway and bulky flap reconstruction may cause oedema around the airway making extubation even more challenging than the intubation [2,3].
All head and neck cancer patients should be in the best possible medical condition before facing surgery, bearing in mind the status of the tumour and the urgency of the procedure . The importance of proper attention to any medical disorder and airway assessment during pre-anaesthetic preparation cannot be overemphasized. Treatment of all medical disorders should be optimized before taking the patient for surgery. These patients do not usually have pre-existing airway obstruction but managing the airway during the perioperative period may still be difficult.
Anaesthetic and surgical management of potential supraglottic obstruction includes five options : (a) oral tracheal intubation by laryngoscopy or fibreoptic bronchoscopy while the patient is awake; (b) awake nasotracheal intubation; (c) inhalational induction of general anaesthesia with intubation; (d) rapid sequence induction with barbiturates and muscle relaxants with intubation and (e) tracheostomy under local anaesthesia.
Awake intubation requires good analgesia of the airway and this can be achieved with a nerve block and/or topical anaesthesia. To achieve topical analgesia of the upper airway, 4% lidocaine is applied with a high-flow atomizer creating a fine, dense, deeply penetrating spray. For adequate anaesthesia of the larynx itself, the patient should breathe deeply while the pharyngeal region behind the base of the tongue is being sprayed. For nasal intubation, preparation of the nostril is required by spraying with 0.05% oxymetazoline hydrochloride to reduce the risk of bleeding. The nostril selected for intubation is dilated by gently inserting soft, progressively larger nasal airways coated with 2% lidocaine gel. Nerve blocks are frequently contraindicated by the presence of tumour in oral cancer patient . Awake oral or nasotracheal intubation by either laryngoscope or fibreoptic bronchoscope is not a preferred choice in supraglotic obstruction including oral cancer . Good local analgesia for successful intubation is difficult to attain in these cases because of the pathology and at worst may be associated with serious and potentially fatal complications due to laryngeal spasm, which may lead to total obstruction and hypoxia [6-8]. Awake intubation is technically difficult due to anatomical changes and also passing the endotracheal tube over the fibreoptic bronchoscope is very difficult or sometimes even impossible during awake intubation . Coughing and straining during awake intubation may cause trauma and bleeding from a tumour further worsening the condition.
Inhalational induction of general anaesthesia and rapid induction with barbiturates and muscle relaxant with intubation are the two preferred choices at our centre. We usually use a combination of these two techniques depending on the patient's medical conditions. Respiration may become obstructed when the patient first loses consciousness with inhalational anaesthesia. Insertion of a nasal airway at this stage may help in the smooth induction of anaesthesia [5,8]. Approximation of the soft palate to the posterior pharyngeal wall was found to be the main reason for obstruction in recent studies and not the tongue falling back as previously thought [9,10]. Use of a nasal airway in these conditions helps in maintaining the airway, and is very useful at this stage and was validated by our retrospective study as in none of our cases was there arterial desaturation. The insertion of an oral airway at this stage may induce laryngeal spasm and so it should be avoided.
In all cases of repeat surgery and in patients where mouth opening was inadequate for insertion of direct laryngoscopy, a fibreoptic intubation with spontaneous ventilation was performed after inhalational induction of general anaesthesia. In the remaining cases where positive pressure ventilation was adequate we used a muscle relaxant and then nasotracheal intubation could be performed. In cases where we were able to establish adequate positive pressure ventilation with a nasal airway, subsequent use of a neuromuscular blocker did not lead to any problem including hypoxia. In all cases arterial blood-gas analysis after intubation was within normal limits.
In only 20 out of the 260 patients was the trachea extubated immediately in the postoperative period. The size of the tumour is clearly important in that it dictates the extent of the tumour resection and influences the methods of reconstruction. A pectoralis major flap tunnelled through the neck carries a greater risk of airway obstruction due to its bulk than does a free flap [3,11]. The chances of postoperative local oedema are greater with bilateral neck dissection. So we routinely keep the trachea intubated and the patient sedated overnight in the surgical ICU when a bilateral neck dissection or pectoralis major myocutaneous flap is performed. In about 90% of cases in our study tracheal extubation was undertaken next morning when the following criteria were met: stable cardiorespiratory status, fully conscious with good protective reflexes, audible leak around the nasotracheal tube with positive pressure ventilation, minimal secretion through nasotracheal tube, oropharyngeal oedema has subsided as evidenced by absence of drooling of saliva from mouth and chest X-ray shows no significant collapse or consolidation.
None of our patients needed a tracheostomy preoperatively for airway management. This procedure is technically difficult and a tracheostomy tube connected to the breathing circuit causes problem during neck dissection and flap reconstruction. At our centre all elective tracheostomy procedures were performed at the end of surgery in oral cancer patients undergoing major resections.
Tracheostomy was the traditional method for maintaining the airway in patients who have a radical resection for head and neck cancer. The role of a tracheostomy in these cases is now debatable because the need for a secure airway has to be balanced against the increased morbidity associated with the procedure . There are many reports of severe complications and occasional death with tracheostomy [12,13]. Halfpenny and McGurk analyzed tracheostomy-associated morbidity after operations for head and neck cancer, and an 8% complication rate were reported half of which were serious complications including obstructed or displaced tracheostomy tubes, stomal recurrence, tracheo-oesophageal fistula and tracheal stenosis. Castling and colleagues reported an 11% minor complication rate in their study. In our study none of our patients had any major complications related to tracheostomies. Only three patients had a minor wound infection at the tracheostomy site. Complications of tracheal intubation with modern materials and techniques are unlikely with periods of intubation less than 48 h [14,15]. Apart from this, nasotracheal intubation has the advantage that the patient is able to speak after extubation and this greatly improves patients' morale and stomal problems which often delay discharge from hospital . A viable alternative to tracheostomy is to maintain nasoendotracheal intubation for up to 48 h postoperatively [16,17]. We use tracheostomy only when absolutely indicated. We had to perform an emergency tracheostomy in only three patients of which two were performed for upper airway obstruction and the other for ventilatory support for severe respiratory infection. The chest infection rate reported in major head and neck surgery was 11% and it increases to 20% in tracheostomized patients . In the present study out of 260 patients only one patient had a chest infection.
In conclusion, oral cancer patients have potential for a difficult airway but, if managed properly during the perioperative period, morbidity and mortality can be reduced or avoided. Our experience showed that oral cancer patients can be managed safely without the routine use of tracheostomy. Nasotracheal intubation is a safe alternative to tracheostomy in the majority of patients undergoing surgery for oral cancer.
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