1. Carcinoma buccal mucosa Moderator: Dr. Bhalla Presenter: Dr. Dipal
Case presentation
Carcinoma buccal mucosa
Moderator: Dr. Bhalla
Presenter: Dr. Dipal

2. 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

3. HISTORY Ulcer Rt buccal mucosa 5 mths back
Gradually progressive in size
Non traumatic
Insidious onset
Initially painless, pain – 3 months
Medications no relief

4. 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

5. 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

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

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

8. 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

9. SYSTEMIC EXAMINATION:
CVS:
Apex beat 5th intercostals space
S1, S2 normal
No murmurs
RESPIRATORY:
Trachea midline
B/L Air entry equal
No added sounds

10. SYSTEMIC EXAMINATION:
CNS:
Higher functions normal
NAD
PA:
Soft
No fluid thrill

11. 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

12. 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:
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

13. 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

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

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

16. 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

17. 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

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

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

20. 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

21. 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

22. 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

23. 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

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

25. 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

26. 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

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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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°

37. 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

38. 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

39. 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

40. “LEMON” Assessment
L - Look externally (facial trauma, large incisors, beard, large tongue) E - Evaluate 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

41. Difficulty
None
Moderate
Severe

42. 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

44. 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)

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

46. 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

47. 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%

48. 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

49. 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

50. 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

51. 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

53. LMA in ASA DA algorithm

54. 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

55. 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

56. 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

60. 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

61. 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

62. 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

63. 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

64. 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

65. 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

66. DGAI guidelines (Anasth Intensiv Med Mar2004;45)
4 stage scheme

67. DGAI guidelines
Decission to more invasive approach to be made in stages

68. DGAI guidelines
Strategy aimed at most minimal invasiveness

69. DGAI guidelines

70. 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