Anaesthetic Management of Laryngectomy

1. Patient Assessment and Preoperative Optimisation

• Elderly male smokers with laryngeal/hypopharyngeal squamous cell carcinoma
• High prevalence of comorbidities: ischaemic heart disease, COPD, hypertension, peripheral vascular disease
• Nutritional compromise - often significant (dysphagia, alcoholism)
• Prior radiotherapy (common) - creates tissue fibrosis, reduces mouth opening and neck mobility, and makes mask ventilation harder
• Alcohol and tobacco dependency - CAGE screening; alcohol withdrawal risk

• Review all imaging (CT/MRI neck, nasendoscopy) - assess degree of airway obstruction, tumour extension, neck mobility
• Assess mouth opening, neck extension, thyromental distance, Mallampati score, and previous intubation records
• Optimise COPD, cardiac disease, and nutritional status pre-operatively
• If lung function is poor, plan for elective postoperative ventilation in ICU
• Multidisciplinary pre-operative airway planning with the surgeon is mandatory - agree on timing of tracheostomy and intubation strategy before theatre

2. Airway Management at Induction

Strategy options:

• Feasible when the lumen is adequate and there is no major distortion
• RSI may be considered but cricoid pressure is best avoided if there is concern about compressing the tumour or compromising the view
• Videolaryngoscopy is useful as a first-line technique in this patient group

• Indicated when tumour bulk, restricted mouth opening (trismus from RT), restricted neck mobility, or previous failed intubation makes asleep intubation unsafe
• Preferred when there is supraglottic obstruction or a friable, bleeding tumour where instrumentation risks complete obstruction
• Requires patient cooperation, adequate topicalisation (lidocaine spray, nebulisation, transtracheal injection), and sedation (e.g. dexmedetomidine or low-dose midazolam/remifentanil)
• Caution: vigorous coughing during awake intubation can worsen obstruction or displace tumour debris distally

• Used when the airway is severely compromised, intubation may be impossible, or when instrumentation risks displacing malignant tissue into the lower airway
• The tracheostomy incision is placed at the intended stoma site
• General anaesthesia is induced only after the airway is secured

3. Intraoperative Airway Management

The key airway sequence in total laryngectomy:

• This tube is prepped into the sterile field
• A Montandon tube, armoured flexible tube, or south-facing RAE tube is commonly used - shaped to lie flat against the chest, pointing caudally, leaving the surgical field clear
• The surgeon places the tube; the anaesthetist connects it to the breathing circuit via sterile connectors and tubing
• Warning: accidental endobronchial intubation is common here - confirm bilateral ventilation after placement
• The cuff of the stoma tube is periodically deflated/tube briefly removed for suture placement during stoma creation

4. Anaesthetic Technique

Induction agents

• Standard IV induction (propofol + fentanyl/alfentanil ± rocuronium)
• Ketamine is useful if severe airway obstruction is anticipated (preserves airway tone and spontaneous ventilation)

Maintenance

• Balanced technique is preferred over deep inhalational alone or pure TIVA:
  • Volatile agent (sevoflurane or desflurane) + opioid infusion
  • Remifentanil infusion is valuable when neuromuscular blockade must be avoided (nerve monitoring during neck dissection phase)
• TIVA (propofol ± remifentanil) is an alternative - particularly useful if there is concern about PONV or when fire risk from electrocautery near an open airway is a concern (avoids ignition of volatile agent from the open stoma, though risk with modern cuffed tubes is low)

Neuromuscular blockade

• NMB with rocuronium or atracurium is acceptable at the start
• Facial nerve / recurrent laryngeal nerve / spinal accessory nerve monitoring during the neck dissection phase requires discontinuation of NMB - switch to remifentanil for analgesia/immobility
• Sugammadex availability is essential for rocuronium reversal when nerve monitoring begins

Fluid management

• Arterial line placed after induction - use systolic pressure variation or pulse pressure variation to guide fluid therapy
• Central venous line is often not needed; a second large-bore peripheral IV is generally sufficient
• Avoid excessive crystalloid - causes surgical site oedema, impairs flap perfusion, and increases the risk of anastomotic leak
• Blood loss can be significant if major vessels are entered; cross-match 2 units PRBC

Positioning-related risks

• Bilateral internal jugular vein (IJV) ligation (in radical neck dissection) causes venous hypertension intracranially - avoid head-down positioning, keep head slightly elevated
• Carotid sinus stimulation during dissection - anticipate bradycardia and arrhythmias; have atropine ready
• Prolonged surgery (4-10 hours) - pressure area care, eye protection, anti-embolism stockings + sequential compression devices

5. Concurrent Free Flap Reconstruction

• Duration typically 8-14 hours - plan for thermoregulation (warming blanket, fluid warmer), eye care, pressure areas
• Haemodynamic goals for free flap viability:
  • Maintain MAP 65-80 mmHg - avoid hypotension which causes vasospasm and flap failure
  • Maintain normovolaemia to slightly hypervolaemic state (Hct ~30%)
  • Avoid vasopressors where possible (cause peripheral vasoconstriction); if needed, use vasopressin or low-dose noradrenaline rather than high-dose alpha agonists
  • Mild haemodilution (Hct 28-32%) optimises microvascular flow
  • Avoid hypothermia (below 35°C) - causes vasoconstriction
• ICU admission - when a free flap has been performed, the patient is typically brought to ICU intubated and ventilated, sedated overnight per surgical preference, to allow flap monitoring and avoid the haemodynamic instability of emergence

6. Postoperative Management

Airway

• After total laryngectomy: extubation is straightforward - remove the stoma ETT when standard extubation criteria are met
• Post-extubation: simply place an oxygen mask or humidified oxygen over the stoma
• Critical point: following total laryngectomy, the mouth and nose are permanently disconnected from the trachea - oral/nasal intubation is impossible and harmful. All subsequent emergency airway access must be via the stoma. The patient's notes, bedside, and wristband should prominently state this.
• For supraglottic or hemilaryngectomy: a temporary tracheostomy is in place postoperatively; standard decannulation pathway follows

Analgesia

• Multimodal approach:
  • Regular paracetamol + NSAIDs (if not contraindicated)
  • Opioids (morphine PCA or regular low-dose IV/IM)
  • Dexamethasone (also reduces oedema)
  • Bilateral superficial cervical plexus blocks (landmark or ultrasound-guided) reduce opioid requirements for neck dissection pain
  • COX-2 inhibitors preferred over NSAIDs if flap is present (less effect on platelet function)

Postoperative complications to watch for:

• Haematoma - can compress the stoma or compromise flap; smooth emergence is important; avoid coughing and straining at end of case
• Pharyngocutaneous fistula - typically presents day 7-10; early nutrition via NGT/jejunostomy
• Free flap failure - venous thrombosis most common; regular flap monitoring (colour, capillary refill, Doppler); return to theatre urgently
• Hypothyroidism - if thyroid is removed concurrently; supplementation post-op
• Chylous fistula - thoracic duct injury in left neck dissection

7. Summary of Key Anaesthetic Considerations

• Miller's Anesthesia, 10th edition - "Neck Dissection and Laryngectomy" section (primary anaesthetic reference)
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol 1 - "Laryngectomy" and "Anaesthesia for Head and Neck Surgery"
• Cummings Otolaryngology Head and Neck Surgery - "Total Laryngectomy - Surgical Technique"
• Elsamna et al., J Oral Maxillofac Anaesth - Acute airway management in TL patients (2024 narrative review)