Year :
2024
| Month :
September
| Volume :
18
| Issue :
9
| Page :
UD06 - UD07
Full Version
Challenges in Ventilation during Total Intravenous Anaesthesia in Patients with Laryngectomy Stoma: A Case Report
Published: September 1, 2024 | DOI: https://doi.org/10.7860/JCDR/2024/70686.19856
Saely Shekhar Paunikar, Vivek Chakole, Sanjot Ninave, Sambit Dash
1. Junior Resident, Department of Anaesthesia, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India.
2. Head, Department of Anaesthesia, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India.
3. Professor, Department of Anaesthesia, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India.
4. Senior Resident, Department of Anaesthesia, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India.
Correspondence Address :
Saely Shekhar Paunikar,
T-6, Shalinitai Hostel, DMIHER, Sawangi, Wardha-442107, Maharashtra, India.
E-mail: saely21@gmail.com
Abstract 
The complete excision of the larynx, which includes the hyoid, epiglottis, and varying segments of the upper trachea, is known as a total laryngectomy. This procedure creates a defect that necessitates pharyngeal correction, as well as the formation of a permanent tracheostomy (tracheostome). Following a total laryngectomy, the trachea is brought to the skin as a stoma, and it is no longer anatomically connected to the digestive tract or oropharyngeal cavity. As a result, bag-mask ventilation, face masks, or nasal cannulas cannot effectively provide oxygen to the lungs. Intubation of the trachea from above the stoma via the oral or nasal route will also be unsuccessful. Hereby, the authors present a unique case of 73-year-old male patient with post-laryngectomy undergoing oesophageal dilation under Total Intravenous Anaesthesia (TIVA). Various challenges encountered while ventilating a patient with a laryngectomy stoma during TIVA has been discussed. Authors also emphasised various methods that can be considered for assisting ventilation in emergency scenarios.
Keywords
Difficult ventilation, Oesophageal dilation, Tracheostoma
Case Report
A 73-year-old male, weighing 48 kg, with no known co-morbidities and classified as American Society of Anaesthesiologists (ASA) class 2, had undergone a total laryngectomy 15 years ago. He was scheduled for oesophageal dilatation due to complaints of dysphagia that had persisted for 15 days. Seven days prior, the patient underwent an upper gastrointestinal endoscopy for the removal of a foreign body and was diagnosed with an oesophageal stricture. Because of the total laryngectomy performed 15 years ago for laryngeal cancer, a stoma was created at that time, resulting in the patient being unable to talk; therefore, the history was obtained from relatives.
During the pre-anaesthetic check-up, a tracheal stoma was noted in the anterior neck (Table/Fig 1). Vital signs and laboratory reports were within normal limits, and the patient was scheduled for surgery under Total Intravenous Anaesthesia (TIVA) after obtaining written informed consent.
On the day of surgery, the “Nil By Mouth” (NBM) status was confirmed, and proper suctioning of secretions from the stoma was performed using a 14 French suction catheter. The patient was positioned in the left lateral decubitus position, and standard ASA multiparameter monitors were attached. High-flow oxygen was administered at 15 L/min via the stoma using auxiliary port tubing (Table/Fig 2).
Premedications included were Inj. glycopyrrolate 0.004 mg/kg, Inj. midazolam 0.05 mg/kg, Inj. fentanyl 1 mcg/kg, Inj. ondansetron 4 mg, Inj. propofol 20 mg and Inj. ketamine 30 mg were administered in titrated doses before the insertion of the endoscope. This was followed by the administration of incremental doses of propofol and ketamine for maintenance.
Chest rise was continuously monitored for early signs of apnoea due to the unavailability of an End-tidal Carbon Dioxide (EtCO2) monitor. A Rendell-Baker-Soucek mask was kept on standby for emergency ventilation via the tracheal stoma. An endotracheal tube and tracheostomy tube of sizes 6 mm and 6.5 mm, respectively, were kept on standby for immediate cannulation. Since, the stoma had been decannulated for over 15 years, the chances of tracheal stricture were high; therefore, a percutaneous tracheostomy set was ready before proceeding with the procedure. A Laryngeal Mask Airway (LMA) was also kept available for ventilation through the stoma.
The patient was maintained on propofol, and at the end of the procedure, after the endoscope was removed, the patient was awakened and shifted out after demonstrating that he was awake, conscious, and able to follow commands.
Discussion
Oesophageal Dilation (ED) is a technique used to treat mechanical obstruction of the oesophagus, which can have a variety of causes, such as stenosis, stricture formation, eosinophilic oesophagitis, other inflammatory diseases, cancer, radiation-induced strictures in patients with head and neck cancer, achalasia, and motility disorders (1). A complete laryngectomy is a surgical procedure in which the entire larynx is removed, leaving the trachea and oropharynx discontinuous. The patient’s proximal trachea is mobilised and brought to the skin to form a stoma in the lower anterior neck following laryngeal excision (2).
Patients with a post-laryngectomy stoma experience significant and frequently overlooked consequences for managing their airway during surgery. Due to its position and appearance, the stoma is often misidentified as a tracheostomy (3). Patients recovering from laryngectomy who have a tracheal stoma and are undergoing any other type of surgery while under general or regional anaesthesia present particular perioperative anaesthetic complications.
Pharyngocutaneous fistulas are a common postoperative issue in patients who have undergone laryngectomy. They can manifest as salivary leakage into the soft tissues, erythema around the patient’s stoma or incision, or worsening tenderness at the incision site. Treatment involves the administration of small aliquots (approximately 5 cc) of normal saline through the stoma, which can help break up these secretions and induce a cough reflex (2).
The ASA defines moderate to profound sedation as the goal for procedures in the Emergency Department (ED) (4). In their study, Amornyotin S and Kongphlay S, found that the oesophageal dilation procedure in an endoscopic unit outside of an operating room was frequently performed under intravenous sedation using sedoanalgesic agents such as fentanyl, midazolam, and propofol, either with or without topical anaesthesia (4). A set of perioperative anaesthetic challenges arises when patients with tracheal stomas who have undergone laryngectomy require any other procedure under general or regional anaesthesia. The literature on the anaesthetic care of these individuals is minimal (5).
One technique to ventilate through the stoma involves using a small paediatric facemask or a skin-applied device (6). However, the most effective method for providing emergency oxygenation at a tracheal stoma is to use Bag-mask Ventilation (BVM) equipped with a paediatric facemask or a LMA (3). Another method of ventilation involves placing the catheter mount tip over the stoma. In a 2004 study, Bhalla RK et al., compared two types of masks: the Laerdal paediatric mask and the Ambu mask. They concluded that the Laerdal paediatric mask should be used for early breathing in patients who have undergone laryngectomy (7). In cases of decreased oxygen saturation or inadequate ventilation, securing the airway may be necessary, and a tracheal tube or a laryngectomy tube (J tube) can be inserted. The majority of stomas can accommodate a cuffed tracheostomy tube comfortably.
Due to their relatively quick onset and faster elimination, shorter-acting sedatives such as propofol, ketamine, fentanyl, and midazolam are frequently used for TIVA. Titrated doses of ketamine and propofol can maintain haemodynamic stability and a deep plane of anaesthesia. Injection dexmedetomidine can also be utilised for sedation, as it does not cause respiratory depression. In a randomised controlled study comparing intravenous sedation to general anaesthesia for oesophageal dilation, Sunpaweravong S et al., found that intravenous sedation with dexmedetomidine during oesophageal dilation was equally safe and effective as general anaesthesia (8). Therefore, in present case, these drugs were used for a rapid reversal from the anaesthetic agents.
Conclusion
The anaesthesiologist is continually confronted with the challenge of managing cases of total laryngectomy due to complications such as tracheal stenosis, tracheomalacia, radiation-induced strictures, increased aspiration, and difficulty in ventilation. Therefore, a thorough preoperative evaluation and preparation of the necessary equipment should be completed before the induction of these cases. Induction and management of cases with anticipated difficult ventilation are enhanced by careful preoperative examination and planning, as well as meticulous intraoperative monitoring, which leads to improved prognosis and fewer complications. A well-prepared anaesthesiologist, equipped with all the necessary tools and detailed knowledge about such cases, can prevent complications during the procedure.
Acknowledgement
All authors would like to acknowledge the efforts of all the co-authors in helping in writing and proof reading present case report.
Reference
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[ CrossRef] [ PubMed] | | 7. | Bhalla RK, Corrigan A, Roland NJ. Comparison of two face masks used to deliver early ventilation to laryngectomized patients. Ear Nose Throat J. 2004;83(6):414-16.
[ CrossRef] [ PubMed] | | 8. | Sunpaweravong S, Benjhawaleemas P, Karnjanawanichkul O, Yolsuriyanwong K, Ruangsin S, Laohawiriyakamol S, et al. Randomized controlled trial of intravenous sedation vs general anaesthesia for esophageal dilation with percutaneous endoscopic gastrostomy in esophageal cancer patients. Surg Endosc. 2023;37(7):5109-13. [ CrossRef] [ PubMed] |
DOI: 10.7860/JCDR/2024/70686.19856
Date of Submission: Mar 13, 2024
Date of Peer Review: May 31, 2024
Date of Acceptance: Jun 26, 2024
Date of Publishing: Sep 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 14, 2024
• Manual Googling: Jun 01, 2024
• iThenticate Software: Jun 25, 2024 (10%)
ETYMOLOGY: Author Origin
EMENDATIONS: 7
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