Case presentationCarcinoma buccal mucosa

Moderator: Dr. Bhalla

Presenter: Dr. Dipal

www.anaesthesia.co.in

anaesthesia.co.in@gmail.com

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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