Carcinoma buccal mucosa Moderator: Dr. Bhalla Presenter: Dr. Dipal Case presentation Carcinoma buccal mucosa Moderator: Dr. Bhalla Presenter: Dr. Dipal www.anaesthesia.co.in anaesthesia.co.in@gmail.com

CHIEF COMPLAINTS: 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

HISTORY 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

PAST HISTORY: No h/o Htn/ DM/ Asthma/ TB No h/o any surgeries/ anesthetic exposure No known drug allergies Family history: non contributory

PERSONAL HISTORY: R/O Kanpur Laborer Vegetarian Tobacco chewer- 5-6 yrs (5 packets/ day) left since 6 mths Non-smoker Non-alcoholic

Examination: 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

SYSTEMIC 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

AIRWAY: Inter-incisor gap: 0.5cm MMP: Length of upper incisors: normal Overbite: Palate: normal Neck movements: Normal TMD: >6cm Teeth: intact, no loose or artificial teeth Mandibular protrusion test: nil Submandibular space compliance: normal Length of neck Thickness of neck B/l nostrils patent. R>L

INVESTIGATIONS:: Bilirubin: 0.7 TP/A/G: 8.3/4.5/3.8 OT/PT: 31/20 Hb: 12.9 gm% TLC: 14500 PLT ct: 369000 Urea: 25 S. creat: 1.2 Na/ K: 141/ 5.0 Bilirubin: 0.7 TP/A/G: 8.3/4.5/3.8 OT/PT: 31/20 Alk Po4: 241 X-ray Chest: NAD ECG: WNL

INVESTIGATIONS: 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

SURGERY: Wide local excision + Segmental mandibulectomy + Right sided radical neck dissection

Anaesthetic plan: options Awake fiberoptic intubation Fiberoptic intubation under anaesthesia Blind nasal intubation Airway gadgets: lighted stylets, Retrogarde intubation Surgical airway access

Preanaesthetic preparation: 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

Operation theatre preparation: Difficult airway cart Anesthesia machine Drugs: anesthetic and emergency drugs Standard monitoring (+u/o, temp) Intravenous access Topicalization of airway Nerve blocks

Intra-operative management: Maintanence of anesthesia Fluid supplementation Blood loss Temperature regulation Analgesia

Extubation: Elective intubation Awake, adequate muscle power and tidal volume, obeying commands In ot/ icu Difficult airway cart Tube exchangers/ guides Post-operative analgesia

Difficult Airway: Definitions 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

Definitions (Contd.) 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

Assessment of Difficult Airway History General physical examination Specific tests for assessment Difficult mask ventilation Difficult laryngoscopy Difficult surgical airway access Radiologic assessment

History 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

General Examination 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

Specific Tests Basic categories Evaluation of tongue size relative to pharynx Mandibular space Mobility of the joints TMJ Neck mobility

Inter-incisor Gap 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

Mandibular Protrusion Test 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

Mallampati 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 visible Somsoon-Young’s modification Class IV: soft palate not visible

Significance of MMP Score 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

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

Evaluation of Mandibular Space Thyromental distance (Patil test) Distance from the tip of thyroid cartilage to the tip of mandible Neck fully extended Minimal acceptable value – 7 cm Significance Negative result – the larynx is reasonably anterior to the base of tongue

Thyromental Distance Limitations Little reliability in prediction Variation according to height, ethnicity Modification 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 laryngoscopy Anesthesiology, May 2005

Sternomental Distance (Savva Test) Distance from the upper border of the manubrium to the tip of mandible, neck fully extended, mouth closed Minimal acceptable value – 12.5 cm

Evaluation of Neck Mobility 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°

Neck Mobility: Clinical Assessment 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 (contd.) 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

Combination of Predictors 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

“LEMON” Assessment L - Look externally (facial trauma, large incisors, beard, large tongue) E - Evaluate 3-3-2 rule 3 - inter incisor gap 3 - hyomental distance 2 - hyoid to thyroid distance M - MMP score O - Obstruction (epiglottitis, quinsy) N - Neck mobility Ron and Walls’ Emergency Airway Management

Difficulty None Moderate Severe

Cormack-Lehane Grading of Laryngoscopy 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

Predictors of Difficult Mask Ventilation B: Beard O: BMI > 26 kg/m2 N: Edentulous E: Age > 55 years S: History of snoring Langeron et al, Anesthesiology, November 2006 (bones)

Rapid airway assessment: 1,2,3 test 1 Finger gap TMJ 2 fingers: mouth opening 3 fingers TMD

Predictors of Problems with Back-Up Techniques 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

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%

Radiographic Predictors 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

Radiologic 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

ASA task force on management of DA 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

LMA in ASA DA algorithm

ASA task force on management of DA Strategy for extubation of DA Awake? Adverse impacts on ventilation Further A/w management plan Guide for reintubation Follow up

Limitations of ASA guidelines 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

DAS guidelines (Anaesthesia.2004.59) 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

SIAARTI guidelines (Minerva Anesthesiol 2005;71:617-57) 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 (Planning in unpredicted difficult a/w) 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 predicted 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

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

Extubation strategy 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 www.anaesthesia.co.in anaesthesia.co.in@gmail.com