Laryngectomy + Radical Neck Dissection
Patient phenotype
Advanced laryngeal/hypopharyngeal cancer. 60s-70s, heavy smokers + drinkers, malnourished, often prior radiation. COPD + CAD + cirrhosis common. Often difficult airway preoperatively.
Procedure
Long, complex case (4-8+ hours). Laryngectomy = removal of larynx + permanent tracheostomy (end stoma). Radical neck = sacrifices SCM, IJ, spinal accessory nerve, sometimes lymph nodes en bloc. Often combined with free flap reconstruction.
Anesthetic plan
GETA. Awake fiberoptic intubation if airway concerning (most cases). Tube must be moved during surgery: oral → tracheostomy mid-case. A-line + 2 PIVs. Consider arterial line in upper extremity (carotid manipulation contraindicates ipsilateral BP cuff).
Setup
- ·AFOI cart or video laryngoscope ready
- ·A-line (contralateral arm if possible)
- ·2 PIVs (one for free flap support drugs)
- ·Type & screen 2-4 units
- ·Sterile flexible bronchoscope to assist tracheostomy tube placement
- ·Reinforced or armored ETT for surgical exchange
- ·Forced air warmer + fluid warmer
- ·Foley
Biggest concerns by phase
Difficult airway assessment
Tumor location, prior radiation, neck mobility, oral aperture, mental status. AFOI safest for known difficult airway with intact spontaneous ventilation. Discussion with surgeon on emergency tracheostomy access.
Awake fiberoptic vs asleep
AFOI: topicalize (4% lidocaine atomizer), minimal sedation (dex + small remi), nasal vs oral approach. Watch for sudden airway loss in tumor compromise.
Carotid sinus reflex during dissection
Manipulation of carotid bifurcation → vagal stimulation → bradycardia, hypotension. Surgeon may inject local around carotid sinus. Have atropine + glycopyrrolate ready.
Tube exchange (oral → tracheal)
Surgeon creates tracheal opening, anesthesia withdraws ETT to above stoma, surgeon places tracheostomy tube, anesthesia connects circuit. Confirm position, ETCO2, cuff inflation. Loose connection = catastrophic loss of airway.
Free flap support if reconstruction
If ALT or radial forearm flap reconstruction: maintain MAP > 80, hematocrit 25-30%, normothermia, avoid alpha-agonists if possible (vasoconstrict flap). See free flap case for full detail.
Long case management
DVT prophylaxis (heparin/SCDs), foley, position checks, fluid balance. Post-radiation tissue may bleed unexpectedly.
Tracheostomy emergence + ICU disposition
Tracheal tube remains, patient awakens with stoma. Adequate suction. Ventilation transition. ICU for 24-48h with humidified circuit, frequent suctioning.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
65-yo M, T4 laryngeal SCC, prior radiation 40Gy, stridor at rest, oxygen sat 91% RA, BMI 22, COPD on inhalers. Total laryngectomy + neck dissection + free flap. Plan?
What an examiner probes for
- ▹AFOI mandatory in this airway
- ▹Discusses surgical airway plan if AFOI fails
- ▹Plans tube exchange to tracheostomy
- ▹Free flap support strategy
- ▹ICU disposition
Sources
- Miller's Ch 66
- Hagberg Difficult Airway 4e
Anatomy reference
Sourced reference images. 4 matches for "larynx neck thyroid trachea".
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