Case presentationCarcinoma buccal mucosa
Moderator: Dr. Bhalla
Presenter: Dr. Dipal
www.anaesthesia.co.in
30 yr/ M/ 55kg Resident of U.P.
Ulcer over Rt buccal mucosa – 5 months Swelling over Rt cheek – 4months ↓ mouth opening – 4 months Rt submandibular swelling – 12 days
CHIEF COMPLAINTS:
Ulcer Rt buccal mucosa 5 mths back Gradually progressive in size Non traumatic Insidious onset Initially painless, pain – 3 months Medications no relief
HISTORY
Swelling Rt cheek since 4 mths Gradually progressive Associated with pain
Painful and reduced opening of mouth since 4 mths
Gradually progressive to MO <1 finger
HISTORY
Noticed swelling in Rt submandibular region – 12 days, non-tender, non progressive
No h/o dysphagia, odynophagia, bleeding from ulcerated growth
No h/o difficulty in breathing, stridor No h/o difficulty in moving tongue No h/o any radiotherapy or chemotherapy
HISTORY:
No h/o Htn/ DM/ Asthma/ TB No h/o any surgeries/ anesthetic exposure No known drug allergies
Family history: non contributory
PAST HISTORY:
R/O Kanpur Laborer Vegetarian Tobacco chewer- 5-6 yrs (5 packets/ day)
left since 6 mths Non-smoker Non-alcoholic
PERSONAL HISTORY:
Conscious, oriented, co-operative No pallor, icterus, cyanosis, clubbing Lymphadenopathy: submental 1*1 cm submandibular 2*2
cm Pulse: 86/min regular BP: 126/ 84 mm of Hg Rt arm supine
position RR: 24/min regular
Examination:
CVS: Apex beat 5th intercostals space S1, S2 normal No murmurs
RESPIRATORY: Trachea midline B/L Air entry equal No added sounds
SYSTEMIC EXAMINATION:
CNS: Higher functions normal NAD
PA: Soft No fluid thrill
SYSTEMIC EXAMINATION:
1. Inter-incisor gap: 0.5cm2. MMP:3. Length of upper incisors: normal4. Overbite: 5. Palate: normal6. Neck movements: Normal7. TMD: >6cm8. Teeth: intact, no loose or artificial teeth9. Mandibular protrusion test: nil10. Submandibular space compliance: normal11. Length of neck12. Thickness of neck13. B/l nostrils patent. R>L
AIRWAY:
Hb: 12.9 gm% TLC: 14500 PLT ct: 369000 Urea: 25 S. creat: 1.2 Na/ K: 141/ 5.0
INVESTIGATIONS::
Bilirubin: 0.7TP/A/G: 8.3/4.5/3.8OT/PT: 31/20Alk Po4: 241
X-ray Chest: NAD
ECG: WNL
Biopsy: Rt buccal mucosa s/o squamous cell ca
CECT: infiltrating soft tissue growth medial to Rt ramus of mandible extending to subcutaneous tissue at level of alveolar margin of maxilla and deep in parapharyngeal space with no bone erosion or lymphadenopathy
INVESTIGATIONS:
Wide local excision + Segmental mandibulectomy +
Right sided radical neck dissection
SURGERY:
Awake fiberoptic intubation Fiberoptic intubation under anaesthesia Blind nasal intubation Airway gadgets: lighted stylets, Retrogarde intubation Surgical airway access
Anaesthetic plan: options
Nil per oral Informed written consent Procedure for awake intubation, post op tube Arrange bood & blood products
Premedication: Antacids orally Glycopyrrolate intramuscular Xylometazoline nasal drops Midazolam intravenous
Preanaesthetic preparation:
Difficult airway cart Anesthesia machine Drugs: anesthetic and emergency drugs Standard monitoring (+u/o, temp) Intravenous access Topicalization of airway Nerve blocks
Operation theatre preparation:
Maintanence of anesthesia Fluid supplementation Blood loss Temperature regulation Analgesia
Intra-operative management:
Elective intubation Awake, adequate muscle power and tidal
volume, obeying commands In ot/ icu Difficult airway cart Tube exchangers/ guides
Post-operative analgesia
Extubation:
Difficult airway: A clinical situation in which a conventionally
trained anaesthesiologist experiences difficulty with mask ventilation, difficulty with tracheal intubation or both
Difficult airway: spectrum Difficult : spontaneous/mask ventilation laryngoscopy tracheal intubation
Ref. Anesthesiology, May 2003
Difficult Airway: Definitions
Difficult mask ventilation: A clinical situation when either,
It is not possible for unassisted anaesthesiologist to maintain the SpO2 > 90% using 100% O2 and positive pressure mask ventilation in a patient whose SpO2 was > 90% before the anaesthetic intervention or
It is not possible for the unassisted anaesthesiologist to prevent or reverse signs of inadequate ventilation during mask ventilation
Definitions (Contd.)
Difficult laryngoscopy It is not possibe to see any portion of the
vocal cords after multiple attempts at conventional laryngoscopy (3, ASA)
Difficult tracheal intubation A clinical situation in which intubation
requires more than three attempts or ten minutes using conventional laryngoscopic techniques
Definitions (Contd.)
Optimal attempt at laryngoscopy – can be defined as
Performance by a reasonably experienced laryngoscopist
The use of the optimal sniffing position The use of OELM One change in length/type of blade
Definitions (Contd.)
History General physical examination Specific tests for assessment
◦ Difficult mask ventilation
◦ Difficult laryngoscopy
◦ Difficult surgical airway access
Radiologic assessment
Assessment of Difficult Airway
Congenital airway difficulties: e.g. Pierre Robin, Klippel-Feil, Down’s syndromes
Acquired◦ Rheumatoid arthritis, Acromegaly, Benign and malignant
tumors of tongue, larynx etc. Iatrogenic
◦ Oral/pharyngeal radiotherapy, Laryngeal/tracheal surgery, TMJ surgery
Reported previous anaesthetic problems◦ Dental damage, Emergency tracheostomy, Med-alerts,
databases, previous records
History
Adverse anatomical features: e.g. small mouth, receding chin, high arched palate, large tongue, morbid obesity
Mechanical limitation: reduced mouth opening, post-radiotherapy fibrosis, poor cervical spine movement
Poor dentition: Prominent/loose teeth Orthopaedic/neurosurgical/orthodontic
equipment Patency of the nasal passage
General Examination
Basic categories
Evaluation of tongue size relative to pharynx
Mandibular space
Mobility of the joints
◦ TMJ
◦ Neck mobility
Specific Tests
Inter-incisor distance with maximal mouth opening
Minimum acceptable value > 4 cm Significance : Positive results: Easy insertion of a 3 cm deep
flange of the laryngoscope blade < 3 cm: difficult laryngoscopy < 2 cm: difficult LMA insertion Affected by TMJ and upper cervical spine
mobility
Inter-incisor Gap
Class A: able to protrude the lower incisors anterior to the upper incisors
Class B: lower incisors just reach the margin of upper incisors
Class C: lower incisors cannot reach the margin of upper incisors
Significance Class B and C: difficult laryngoscopy
Mandibular Protrusion Test
Patient in sitting position Maximal mouth opening in neutral position Maximal tongue protrusion without arching No phonation Class I: faucial pillars, soft palate, uvula visible Class II: faucial pillars, soft palate visible Class III: only soft palate visibleSomsoon-Young’s modification Class IV: soft palate not visible
Mallampati Test
Class III or IV: signifies that the angle between the base of tongue and laryngeal inlet is more acute and not conducive for easy laryngoscopy
Limitations◦ Poor interobserver reliability◦ Limited accuracy
Good predictor in pregnancy, obesity, acromegaly
Anesthesia & Analgesia, February 2006
Significance of MMP Score
Correlation between MMP score and laryngoscopy grade
MMP class
Cormack and Lehane grade
Grade 1 Grade 2 Grade 3 Grade 4
Class I (73%) 59% 14% - -
Class II (19%) 5.7% 6.7% 4.7% 1.9%
Class III & IV (8%)
- 0.5% 5% 2.5%
Airway Management, Jonathan Benumof
Thyromental distance (Patil test) Distance from the tip of thyroid cartilage to
the tip of mandible Neck fully extended Minimal acceptable value – 7 cmSignificance Negative result – the larynx is reasonably
anterior to the base of tongue
Evaluation of Mandibular Space
Limitations Little reliability in prediction Variation according to height, ethnicityModification to improve the accuracy Ratio of height to thyromental distance
(RHTMD) Useful bedside screening test RHTMD < 25 or 23.5 – very sensitive
predictor of difficult laryngoscopyAnesthesiology, May 2005
Thyromental Distance
Distance from the upper border of the
manubrium to the tip of mandible, neck
fully extended, mouth closed
Minimal acceptable value – 12.5 cm
Sternomental Distance (Savva Test)
Clinical methods Patient is asked to hold the head erect, facing
directly to the front maximal head extension angle traversed by the occlusal surface of upper teeth
Grade I : > 35° Grade II : 22-34° Grade III : 12-21° Grade IV : < 12°
Evaluation of Neck Mobility
Flexing the head on the neck immobilize the lower cervical spine full head extension angle traversed by the vertex or forehead
Significance
Angle > 90°
Specific test for atlanto-occipital joint extension
Neck Mobility: Clinical Assessment
Placing one finger on the patient’s chin One finger on the occipital protuberance
Result Finger on chin higher than one on occiput
normal cervical spine mobility Level fingers moderate limitation Finger on the chin lower than the second
severe limitation
Neck mobility (contd.)
Wilson Score 5 factors
◦ Weight, upper cervical spine mobility, jaw movement, receding mandible, buck teeth
Each factor: score 0-2 Total score > 2 predicts 75% of difficult
intubations
Combination of Predictors
L - Look externally (facial trauma, large incisors,
beard, large tongue)E - Evaluate 3-3-2 rule
3 - inter incisor gap3 - hyomental distance2 - hyoid to thyroid distance
M - MMP scoreO- Obstruction (epiglottitis, quinsy)N- Neck mobility
Ron and Walls’ Emergency Airway Management
“LEMON” Assessment
DifficultyNone None Moderate Severe
Grade 1: Full exposure of glottis (anterior +
posterior commissure)
Grade 2: Anterior commissure not visualised
Grade 3: epiglottis only
Grade 4: Visualization of only soft palate
Cormack-Lehane Grading of Laryngoscopy
B: Beard
O: BMI > 26 kg/m2
N: Edentulous
E: Age > 55 years
S: History of snoring
Langeron et al, Anesthesiology, November 2006
(bones)
Predictors of Difficult Mask Ventilation
1,2,3 test
1 Finger gap TMJ
2 fingers: mouth opening
3 fingers TMD
Rapid airway assessment:
LMA Insertion Mouth opening < 2 cm Intraoral/pharyngeal masses (e.g. lingual
tonsils)Direct Tracheal Access Gross obesity Goitre Deviated trachea Previous radiotherapy Surgical collar
Predictors of Problems with Back-Up Techniques
Statistical Significance of Bedside Predictors
Diagnostic test Sensitivity Specificity
MMP class 49% 86%
TMD 20% 94%
Sternomental distance
62% 82%
Mouth opening 22% 97%
Wilson risk score 46% 89%
MMP + TMD 56% 97%
X-Ray neck (lateral view) : Atlanto-occipital gap C1-C2 gap Posterior depth of mandible- distance
between the bony alveolar margin just behind 3rd molar tooth and lower border of mandible.
Tracheal compression
Radiographic Predictors
CT Scan: Tumors of floor of mouth, pharynx, larynx Cervical spine trauma, inflammation Mediastinal mass
Helical CT (3D-reconstruction): Exact location and degree of airway
compression
Radiologic Predictors
Basic preparation◦ Inform◦ Ascertain help◦ Preoxygenation◦Supplemental
oxygenation throughout
Portable storage unit Rigid laryngoscope
blades ETTs ETT guides LMAs FFOI equips RI Em NI a/w vent Em invasive a/w Exhaled CO2 detector
ASA task force on management of DA
Strategy depending on◦ Anticipated surgery◦ Patient condition◦ Skill & preference of anaesthesiologist
4 basic problems 3 basic management choices Primary approach Alternative approach Exhaled CO2 to confirm tracheal
intubation
ASA task force on management of DA
LMA in ASA DA algorithm
Strategy for extubation of DA◦ Awake?◦ Adverse impacts on ventilation◦ Further A/w management plan◦ Guide for reintubation
Follow up
ASA task force on management of DA
Open ended, wide choice of techniques Emphasis on prediction of difficult airway No stratification of available a/w devices No expression of strength of
recommendation
Limitations of ASA guidelines
Management of un-anticipated difficult intubation in an adult non-obstetric patient
Paediatric, obstetric patients & patients with upper a/w obstruction excluded
Flow charts based on series of plans Careful planning with backup plans Maintenance of oxygenation takes priority Seek the best assistance available
DAS guidelines(Anaesthesia.2004.59)
Doesn’t apply to paediatric patients Defines strength of expressed
recommendation Defines difficult a/w control, ventilation,
intubation & laryngoscopy Difficulty prediction (severe/borderline) Devices managament
◦ Mandatory◦ Other devices, available upon request◦ Other mentions
SIAARTI guidelines(Minerva Anesthesiol 2005;71:617-57)
Correct position Alternative options (blade/stylet/introducer/
magill’s) Oxygenation is mandatory Urgency/ emergency of procedure
Elective sx Deferrable urgent sx Emergent sx
SIAARTI guidelines (Planning in unpredicted difficult a/w)
Immediate withdrawal in CL – IIIe & IV Preliminary knowledge of alternative
devices, training in FOI Blind intubation via extraglottic devices not
recommended in emergency/ after repeated attempts
Use of fiberscope in emergency situations is not recommended
SIAARTI guidelines (Planning in unpredicted difficult a/w)
Strategy depends upon◦ Surgery deferrability◦ Risk of vomiting◦ Skill of anaesthesist◦ Available instrumentation◦ Patient cooperation◦ Grade of predicted difficulty
SIAARTI guidelines (Planning in predicted difficult a/w)
Predicted severe DA◦ Maintain consciousness, spont. Breathing◦ 1st choice – awake FOI◦ Surgery under RA not recommended◦ Intubation under direct vision◦ Retrograde intubation as an alternative to FOI
SIAARTI guidelines (Planning in predicted difficult a/w)
Predicted severe DA◦ Anaesthesia can be induced◦ Preoxygenation & ventilability evaluation◦ Laryngoscopy grading influences further choice
CVCI◦ 1st choice- cricothyrotomy◦ Surgeons intervention as an exception
SIAARTI guidelines (Planning in predicted difficult a/w)
DGAI guidelines(Anasth Intensiv Med Mar2004;45)
4 stage scheme
DGAI guidelines
Decission to more invasive approach to be made in stages
DGAI guidelines
Strategy aimed at most minimal invasiveness
DGAI guidelines
Cuff leak test Performed in a spontaneously ventilating patient at risk of obstruction after extubation
Circuit disconnected occlusion of ETT end and deflation of cuff ability to breath around the ETT
Conventional awake extubation
Extubation in a deep plane of anaesthesia followed by placement of LMA to decrease the risk of laryngospasm
Extubation over a fibreoptic bronchoscope
Endotracheal ventilation and exchange catheters e.g. ◦ Cook’s airway exchange catheter◦ Tracheal tube exchanger
Extubation strategy
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