This document discusses the anesthetic considerations for head and neck oncosurgical procedures. It begins with an overview of the epidemiology of head and neck cancers and risk factors. It then discusses preoperative evaluation focusing on airway assessment, cardiovascular, pulmonary, and cancer-related complications. Intraoperative management focuses on securing the airway, fluid management, positioning, and complications related to specific procedures like thyroidectomy. Postoperative concerns include airway management, bleeding, hypocalcemia, and thyroid storm. Collaboration between the surgeon and anesthesiologist is emphasized for safe management.

1. D R N A Y A N A K U L K A R N I
C M C C
N A S I K
Anesthetic Considerations In Head
Neck
Oncosurgical Management

2. Objective
1/16/2016
dr nck cmcc nasik
2
 At the end of this session the delegate should have a
fair idea of:
 The peri-operative management of patients
undergoing surgery related to head and neck cancer

3. Head and neck cancer
1/16/2016
dr nck cmcc nasik
3
 Worldwide 644k incidence and 350 k deaths
• 50,000 Americans are diagnosed with a head or neck
cancer (not including skin cancers that occur in the
head or neck)
~ 5 percent of all cancers in the US
– Majority are squamous cell carcinoma
• Survival rates have improved
– aggressive treatment
– early detection
– declining rates of tobacco and ETOH abuse
• The role of HPV
– The % of oropharyngeal cancers caused by human
papillomavirus (HPV) has increased
– 80% of oropharyngeal cancers are now caused by HPV
(industrialized countries)

4. Epidemiology
1/16/2016
dr nck cmcc nasik
4
 Head and Neck Squamous cell carcinoma
(HNSCC), which constitutes the most common
upper aero digestive tract carcinomas.
 Accounts for 3% of all cancers in the developed
countries like USA whereas in developing countries
like India it accounts for 30% of all cancers.

5. EPIDEMIOLOGIC TRENDS OF HEAD AND NECK
CANCERS
1/16/2016
dr nck cmcc nasik
5
 Head and neck cancers are among the 10 most
common cancers globally.
 In India, it accounts for one fourth of male cancers
and one tenth of female cancers (Yeole 2001).
 Risk factors for head and neck cancers:
 Consumption of alcohol,
 Tobacco smoke,
 smokeless tobacco,
 alcohol,
 marijuana use,
 deficient diet,
 Human Papilloma virus infection

6. General considerations for HNF surgery
1/16/2016
dr nck cmcc nasik
6
• Airway Management
– Anatomy (c-spine, +/- ROM, large tongue) – stridor
or hoarseness
– hx neck surgery, trauma, difficult intubation –
infections (epiglottitis, abscess)
– head/neck cancer radiation therapy
 low threshold for fiberoptic
• backup plan
• sharing of airway with surgeon
• nasal intubation

7. Anesthetic considerations
1/16/2016
dr nck cmcc nasik
7
 Problems related to age
 Problems related to cancer
 Securing airway
 Recovery

8. Age
1/16/2016
dr nck cmcc nasik
8
 Generally older patients
 Cardiac- Co dec by 1% per yr after 30 yrs so ability
to in response to stress is diminished.
 Respiratory – PaO2 by 0.5% per yr after 20 yrs, so
rapid hypoxemia esp if pt is smoker
 Hepatic – drug clearance is impaired.
 Renal- cr clearance also dec 1ml/min/yr after 20
yrs it means high sr creat may indicate underlying
severe impairment in clearance.

9. Cancer
1/16/2016
dr nck cmcc nasik
9
 Chemo is given to cause tumor reduction.
 It can result in affection of multiple systems in body
Due to cumulative dosages and drug toxicity:
 Renal
 Hepatic
 Hematological / bone marrow suppression
 Cardiac
 Pulmonary
 GI

10. Post radiotherapy
1/16/2016
dr nck cmcc nasik
10
 Airway fibrosis
 Lung toxicity
 Restrictive cardiomyopathy
 Metabolic-
 Tumor cell destruction
 Tumor produced factors
 Electrolyte imbalances

11. Preoperative evaluation
Wyss, A. et. Al Am. J. Epidemiol. (2013) 178 (5): 679-690. doi:
10.1093/aje/kwt029
1/16/2016
dr nck cmcc nasik
11
 Determine degree of compromise and risk
 Focus preliminary exm on CVS , Airway and
Pulmonary systems.
 – elderly comorbidities
 – hx of smoking, EtOH
 – Hx CAD, HTN, CRI, COPD
 – Prior anesthesia hx
 – preop testing imaging studies, PFTs, cardiac
and hepatic function

12. Preoperative
evaluation
1/16/2016
dr nck cmcc nasik
12
 Increasing risk factors-
 Obesity
 age> 60
 h/o smoking
 PaCO2 > 45 mm Hg
 Max breathing capacity of < 50% of predicted in PFT’s
 Presence of pulmonary disease itself is predictor of
high incidence of peri- operative pulmonary
complications
 Proper preop preperation in pt with pulmonary
disease can reduce periop morbidity and mortality
 Bronchodilators,mucolytics,incentive
spirometry,abstinance from abusive agents, coughing
and deep breathing.
 PFT- normalises by 8 wks.
 Reduction in COHb- 12 hrs.
 Stain M JAMA 211,787, 1970

13. 1/16/2016
dr nck cmcc nasik
13

14. Images –difficult airway
1/16/2016
dr nck cmcc nasik
14

15. 1/16/2016
dr nck cmcc nasik
15

16. 1/16/2016
dr nck cmcc nasik
16

17. 1/16/2016
dr nck cmcc nasik 17

18. 1/16/2016
dr nck cmcc nasik
18

19. 1/16/2016
dr nck cmcc nasik
19

20. Dr. Binnions Lemon Law: An easy way to
remember multiple tests…
1/16/2016
dr nck cmcc nasik
20
• Look externally.
• Evaluate the 3-3-2 rule.
• Mallampati.
• Obstruction?
• Neck mobility.

21. 1/16/2016
dr nck cmcc nasik
21

22. Golden pearls
1/16/2016
dr nck cmcc nasik
22
 Fluid management in Cancer surgeries.
 Rehydration
 maintainance
 Replacement
 Other goals-
 Early ambulation
 Chest PT
 Recognise difficult airways and prepare for it.

23. General Considerations
1/16/2016
dr nck cmcc nasik
23
• Anesthetic Management –
-Smooth emergence
-Opioid based technique
-antiemetic prophylaxis
- OGT prior to emergence to empty stomach
+/-
– General with ETT vs. flexible ETT

24. General Considerations
1/16/2016
dr nck cmcc nasik
24
Adequate intra op/postop analgesia,
highly reflexogenic areas –
controlled hypotension –
decrease SBP< 100mmHg,
Keep MAP 60-70
Pt immobility muscle relaxation ?

25. Monitoring and access
1/16/2016
dr nck cmcc nasik
25
– ECG
– BP noninvasive vs. Arterial
– pulse Ox
– temp
– end tidal CO2
– RLN nerve monitoring current practice
– large bore IV, good access large bore IV, good
access
– positioning arms tucked, all access prior,
sticky pulse ox, nerve stimulator (where?)

26. Intraoperative
1/16/2016
dr nck cmcc nasik
26
- Protect eyes
– Cardiac function monitored
– Temp
–Head of bed can be elevated aids venous
drainage
– +/- Reinforced ETT
–Avoid drugs that stimulate sympathetic nervous
system

27. Options
1/16/2016
dr nck cmcc nasik
27
 ETT with GA
 Awake FOI
 Awake DL and then assess intubation status
 Recent IDL to predict level of difficulty
 Trach with LA

28. Difficult mask ventilation
1/16/2016
dr nck cmcc nasik
28
 Age>55
 Presence of beard
 BMI >26
 Edentulous
 h/o snoring
 Massive jaw
 Poor neck extension
 Large tongue
 Mandibular space
 TMD
 MMP
 Neck
 Pharyngeal pathology
 Facial deformity
 Facial dressings
 Tumor growth on face
 h/o difficult airway
 Overbite
 shape of palate
 Inter incisor length
 Cervical vertebral ROM

29. Intraop airway management
1/16/2016
dr nck cmcc nasik
29
 Secure ETT prefer reinforced ETT
 Assess Surgical field requirement accordingly fix
ETT
 Trach as an when indicated
 Prolonged reconstructions- keep head end elevated
to minimise supraglottic edema
 Give dexamentasone
 Minimise ETT movement

30. Extubation
1/16/2016
dr nck cmcc nasik
30
 Keep tube exchanger at hand (bougie)
 Jet ventilation /both
 Preferably Keep lengthy and reconstructive
surgical pts intubated overnight.
 Criterias for extubation-
 Severity of pulmonary disease
 Length and extent of surgery
 Ability to protect airway
 Ability to mobilize and remove secretions
 Amount of residual respiratory depression from
residual anesthetic agents

31. Thyroidectomy
1/16/2016
dr nck cmcc nasik
31
 Maintain adequate depth of anesthesia –
Remember DL is stimulant
– B-blockers are your friend
• Not particularly painful post-op.
– Complete reversal intact reflexes
– Recurrent Laryngeal Nerve Damage
• unilateral = hoarseness
• bilateral = aphonia and stridor

32. Thyroidectomy
1/16/2016
dr nck cmcc nasik
32
–Hematoma formation
–Hypoparathyroidism unintentional removal
of parathyroid glands.
(Chvostek’s and Trousseau’s)
–Awake vs Deep extubation

33. Thyroid Storm
1/16/2016
dr nck cmcc nasik
33
 Can occur intraop,
 most common 6-24 hour postop
 – Mimic MH intraop
 –Hyperpyrexia, tachycardia, altered consciousness
hypotension consciousness, hypotension
 – Tx: hydration,
 cooling,
 esmolol infusion,
 propylthiouracil,
 sodium iodide,
 cortisol

34. For Tracheostomy
1/16/2016
dr nck cmcc nasik
34
 • Pre-op Assessment
 – population usually includes: chronically ventilated
pts, pts having other procedure where trach is
required,
 pts with upper airway obstruction (emergency)
 – evaluate pt - ventilation settings
 – airway, coexisting dx
 – cardiac hx
 – neuro assessment may be sedated
 – In OR or Bedside +/- anesthesia

35. Intraop for Tracheostomy
1/16/2016
dr nck cmcc nasik
35
- For intubated pts GETA
–Airway compromised pts local anesthesia
– mucosal swelling
tissue fragility
• risk of tracheal mucosal separation and false passage
during trach
– Communicate with surgeon when using cautery in
the airway
– 100% O2 required before insertion of trach

36. Intraoperative Trach
1/16/2016
dr nck cmcc nasik
36
 Trachea opened above cuff, ETT retracted slowly
with visualization of surgeon (communication),
 do not remove all the way until trach in
place and +ETCO2 confirmation-
• Pneumothorax
• False passage
– recognize, no CO2,
PIP
absent breath sounds,
rigid bronchoscope and extra ETT available

37. Postoperative trach
1/16/2016
dr nck cmcc nasik
37
 Transport to ICU with meds, equipment
– Trach tube displacement,
 ETT and extra trach tube with stylet (obturator)
available
– Watch for bleeding

38. Anesthesia for ND
1/16/2016
dr nck cmcc nasik
38
• Radical, modified, or functional
• Usually performed with resection of primary lesion :
 thyroid,
 parathyroid,
 tongue,
 pharynx,
 larynx, etc.

39. Preop considerations for ND
1/16/2016
dr nck cmcc nasik
39
– Airway decreased mobility
2°to radiation
• backup plan
• surgeon available surgeon available
– Resp COPD,
CO2 retention,
PFTs
– Cardiac: HTN, carotid artery stenosis

40. Intraoperative
1/16/2016
dr nck cmcc nasik
40
– Moderate decrease in BP,
- avoid adrenergic responses
– Muscle relaxant +/-
–Humidify gases reduce mucous plugging
–VAE occurs rarely
– Manipulation of carotid sinus bradycardia,
-- ↓ BP

41. Esp right side neck dissection
1/16/2016
dr nck cmcc nasik
41
• Right Radical Neck dissection -
• may cause prolonged QT interval which may progress
to ventricular arrhythmias and cardiac arrest
(due to interruption of cervical sympathetic outflow to
heart via right stellate ganglion)

42. Postoperative Considerations in ND
1/16/2016
dr nck cmcc nasik
42
 –HTN,
 ↑HR 2° to carotid sinus denervation
 – Facial nerve injury
 – RLN damage
 –Diaphragmatic paralysis
 – Pneumothorax
 –Agitation

43. Special considerations- minor procedures but not
so minor!!
1/16/2016
dr nck cmcc nasik
43
 PEG insertion/ feeding gastrostomy in HN Ca pt on
RT- neck movement negligible,anatomical landmarks
not visible-
 Difficult airway so may need FOI GA PEG
insertion.
 DL in partial stridor pt-
 Discuss possibility of Emergency trach with
relatives in dire conditions as life saving
measure.
 ECA ligation post CT/RT-
 difficult mask ventilation possibility must be
kept in mind.

44. At the end TEAM EFFORT wins
1/16/2016
dr nck cmcc nasik
44