Obstructing tumors of the subglottic larynx and cervical trachea: airway management and treatment

Peristomal recurrence following primary total laryngectomy: the enigma of the central compartment neck lymph nodes

PURPOSE OF REVIEW

The practice of primary total laryngectomy (TL) for advanced laryngo-hypopharyngeal cancer has significantly declined in the developed countries. The treatment options most frequently adopted have changed from open surgery to transoral laser or robotic approaches or nonsurgical (bio-chemo-) radiotherapy. Primary TL remains the treatment of choice in the developing world where healthcare resources are limited, especially for the treatment of cancer.

RECENT FINDINGS

Peristomal recurrence (PSR) is quite a serious complication, with an incidence of 6.6% from the published literature (mainly concerning the developed world), most diagnosed within 2 years, and associated with >80% mortality. The major risk factors include pretreatment tracheostomy, specific primary tumor subsites, positive surgical margins, and presence of nodal metastasis. The treatment options are limited and most success has been observed with surgery, especially when PSR is diagnosed at an early-stage, which is uncommon. Treatment of advanced-stage disease is usually palliative. Reduction and/or prevention of the known risk factors for PSR remain the goal when performing TL. In particular, central compartment (para- and pretracheal) lymph nodes dissection in case of large tumors with extra-laryngeal and/or subglottic extension or pretreatment tracheotomy plays a paramount role in PSR prevention.

SUMMARY

Research is required to conclude the formulation of guidelines for proper dissection of the central compartment (level VI) lymph nodes as indicated either prophylactically or therapeutically during TL for preventing PSR.

Endoscopic airway management of acute upper airway obstruction

The conventional treatment for patients with acute upper airway obstruction is tracheostomy, which is a safe, definitive procedure in most hands. Alternatively, a debulking procedure can be considered but this requires both surgical and anaesthetic skill and expertise. However, where possible, it provides a good alternative with the advantages of removing the cause of obstruction and yielding tissue for histopathological analysis, and avoiding the need for a tracheostomy, with its associated morbidity. We evaluated all patients who presented with acute upper airway obstruction and underwent endoscopic laser debulking surgery performed by the senior author, over a three and a half year period. We recorded patient demographic data, their underlying pathologies, complication rates associated with laser debulking surgery and the conversion to tracheostomy. Thirty patients were identified, including 19 males and 11 females, with a mean age of 57.10 ± 17.20 years (19-93 years). All patients underwent debulking procedures with carbon dioxide laser under general anaesthetic. All patients had their underlying diagnosis confirmed from their debulking surgery. Twelve patients were found to have benign pathology and 18 had malignant airway obstruction. There were no laser-associated complications. One patient required conversion to emergency tracheostomy, during their debulking surgery. Endoscopic laser assisted debulking surgery has successfully been used to establish a safe airway. It allows obtaining tissue specimens, to confirm the underlying diagnosis, thus avoiding the need for further biopsies under anaesthetic. For all malignant cases, patients were subsequently able to proceed to definitive treatment. It has obviated the need for emergency tracheostomy in almost all of the cases in our patient cohort.

Management of airway in patients with laryngeal tumors

STUDY OBJECTIVE

To describe our systematic approach to securing the airway in patients with laryngeal tumors, developed over a 10-year period.

DESIGN

Retrospective analysis.

SETTING

University-affiliated veterans administration medical center.

PATIENTS

Eight hundred one patients presenting for laryngeal tumor surgery in a 10-year period, 285 of whom underwent tracheostomy (25 with local anesthesia and 260 with general anesthesia).

INTERVENTIONS

Preoperative examination, including history, physical examination, computed axial tomography and/or magnetic resonance imaging, and ear, nose, and throat surgeons' evaluation via indirect laryngoscopy or fiberoptic bronchoscopy were performed before the anesthesiologist's interventions. Local (topical) anesthesia and mild sedation were used for laryngeal evaluation with fiberoptic bronchoscopy. Tumor grade was then established, which determined how the airway would be secured: general anesthesia induction, receive topical anesthesia for awake, direct laryngoscopy, and tracheal intubation, or undergo tracheostomy with local anesthesia.

MEASUREMENTS AND MAIN RESULTS

When the airway was secured, surgeons performed the biopsy, (any) tumor debulking, laser excision, or tracheostomy to establish both the airway and the diagnosis. Pulmonary function, including flow-volume loops and blood gas analysis were also useful in evaluating the degree of obstruction and gas exchange. In the event of respiratory distress, tracheostomy was performed after tracheal intubation or with local anesthesia, followed by direct laryngoscopy and biopsy. Depending on the diagnosis, further surgery and radiation treatment were planned next.

CONCLUSIONS

With these guidelines, we have reduced the frequency of emergencies because of a lost airway, bleeding, or dislodging of tumor.

Laser debulking in malignant upper airway obstruction

BACKGROUND

The conventional treatment for patients with upper airway obstruction secondary to malignancy is a tracheostomy. Although this effectively resolves the problem, a tracheostomy can be associated with complications and is irreversible in most patients. An alternative is to debulk part of the tumor causing airway obstruction to maintain the airway until the definitive procedure.

METHODS

The clinical course of 43 patients who underwent laser debulking for airway obstruction caused by laryngeal or hypopharyngeal malignancies was retrospectively studied. We present our technique of laser debulking and the efficacy of the procedure in avoiding a tracheostomy.

RESULTS

Fourteen patients who underwent this procedure received palliative treatment only. The number of debulking procedures per patient ranged from one to six, with a mean of 1.9 episodes. Although these patients had a higher comorbid burden, none were thought unsuitable for the procedure. A tracheostomy was avoided in 91% of patients. No laser-related complications were encountered.

CONCLUSIONS

Laser debulking is a viable alternative to tracheostomy in patients with malignant upper airway obstruction.

Subglottic Carcinoma: Review of a Series and Characterization of its Patterns of Spread

The rarity of primary subglottic malignancies, along with the varied definitions of the anatomic confines of this region, have limited our understanding of the patterns of tumor spread within the subglottis. We conducted a retrospective chart review to analyze clinical and pathologic data in patients with subglottic carcinoma. A pattern of disease progression was identified, which is defined by the cartilaginous laryngeal framework, with the fibroelastic barriers susceptible to tumor invasion.

We conclude that although cartilaginous laryngeal structures are preserved until late in the disease course, the ability of tumors to invade the fibroelastic membranes provides them with an insidious means of escape. Specifically, tumor progression occurs primarily within the paraglottic space and extralaryngeal compartments; the potential for mucosal spread is limited. The lack of mucosal disease in patients whose cartilaginous laryngeal structures are intact may present a facade of normality in patients with advanced disease, and perhaps delay the early diagnosis of subglottic malignancies by physical and radiologic examination.

Treatment of the patient with upper airway obstruction caused by cancer of the larynx

The treatment of a patient with imminent airway obstruction caused by a malignant tumor of the larynx is an uncommon clinical problem. These cases need to be evaluated, diagnosed, and managed with care, skill, speed, and above all, appropriateness of intervention. Three methods are available to control the airway: tracheostomy, emergency laryngectomy, and controlled tracheal intubation with or without tumor debulking. Two groups of patients had their airways managed either by tracheostomy and delayed elective surgery or by emergency laryngectomy. There was no survival advantage between the groups, and no increased risk of stomal recurrence was demonstrated. If time permits, the patient is considered suitable, and adequate anesthetic and surgical instrumentation is available, it is currently recommended that the obstructing laryngeal tumor be debulked by cold-steel or, preferably, CO2 laser and that the emergency situation be stabilized and the definitive treatment of the patient be converted to an elective procedure without the need to create a tracheostomy.

Laser debulking of obstructing laryngeal tumours

A consecutive series of 11 patients presenting with obstructing laryngeal neoplasms over an 8-month period have been treated by laser debulking of the tumour in order to avoid a tracheotomy. Providing that all members of the team are experienced in microlaryngeal laser surgery, this technique can be safely and effectively used in the management of obstructing laryngeal neoplasms.

Anesthesia for microlaryngeal surgery: the case for subglottic jet ventilation

Although the techniques for surgery on the endolarynx using suspension and the operating microscope have been fully developed, the safest, and least obtrusive anesthetic technique has yet to be manifested, as evidenced by more than 200 references to anesthesia for microlaryngoscopy in the world literature. This study reviews the physiology, physics, and problems of each anesthetic technique. In light of this review, animal and human studies are reported demonstrating the utility and safety of subglottic ventilation when provided with proper monitoring using an automatic ventilator. A modified Ben-Jet tube is reported, which has a 1-mm ID channel to monitor PCO2 and tracheal pressure. This self-centering 3.0-mm tube, which extends 6 to 8 cm below the glottis, is unobtrusive for the surgeon. The subglottic tube, which is much less likely to be malaligned, is much more acceptable to the anesthesiologist. Anesthesia, by intravenous sedation, utilizes neuromuscular blockade while ventilating through the jet tube powered by an automatic ventilator with an automatic shutdown feature attached to the monitor tube to prevent inadvertent barotrauma. The third phase of this study compared fluoroplastic, used in a prototype jet ventilation tube, with 6-mm Silastic, Red Rubber, and polyvinyl chloride (PVC) tubes when struck by maximum power of CO2, Nd-YAG, and K-532 lasers. The test was performed in a closed chamber in which concentrations of oxygen and nitrogen were controlled. Although damaged by the CO2 laser beam, the fluoroplastic tubes did not continue burning when the laser was turned off in 100% oxygen, even when coated by blood. The other three tubes continued to burn in 23% oxygen. Neither the KTP nor Nd-YAG laser damaged the Teflon tube, while they ignited a sustained flame in 30% oxygen. This study supports the use of fluoroplastic for a laser safe jet ventilation tube. It also demonstrates the danger of tube fires, even in low oxygen concentrations, when using Silastic, rubber, and PVC tubes in laser laryngeal surgery. There was no difference in the flammability of Silastic, rubber or PVC when struck by these lasers in this study. For these reasons, subglottic ventilation using a fluoroplastic, monitored, self-centering, subglottic, jet ventilation tube driven by an automatic ventilator with a shutdown feature, in the event of excessive pressure buildup, is proposed for anesthetizing healthy patients undergoing suspension microlaryngoscopy, and who have no airway obstructing lesion. A large tube with inflatable cuff is indicated when a supraglottic lesion may obstruct the airway.

Tracheoscope: an old instrument with new applications

The tracheoscope is a bronchoscope without the side ventilating ports at the distal tip. It has been used for decades, implementing diagnostic and therapeutic procedures in the subglottis and cervical and thoracic trachea. The closed tube tracheoscope allows excellent control of the airway with maintenance of continuous anesthesia and ventilation. Flexible fiber-directed lasers, such as the potassium-titanyl phosphate laser, can be used with the tracheoscope for laser resection or vaporization of diseased tissue from just below the vocal cords to any level within the trachea. Controlled anesthesia and smoke evacuation are maintained throughout the operation, allowing a relatively safe endoscopic procedure. Disorders such as subglottic hemangioma, subglottic or tracheal webs, papillomatosis, granuloma, and a variety of neoplastic growths can be excised, debulked, or submitted to biopsy by means of this instrument. In the neonatal and infant airway, use of the tracheoscope concomitantly with rigid telescopes has been particularly rewarding.

Subglottic plasmacytoma: the use of jet ventilation and contact Nd:YAG laser for tissue diagnosis

Extramedullary plasmacytomas (EMP) constitute only 1% of all head and neck malignancies, with the vast majority occurring in the upper respiratory tract. The diagnosis of laryngeal EMP can be difficult since the symptoms are non-specific and the tumor usually mucosally covered. This paper discusses the successful combination of jet Venturi ventilation technique with suspension microlaryngoscopy and contact Nd:YAG laser for tissue diagnosis in a patient presenting with a large subglottic mass. Previous attempts using standard endotracheal intubation and forceps technique for biopsy failed to reach the diagnosis and resulted in significant bleeding from the biopsy site. A review of the disease and technique is presented.

Laser Surgery of the Larynx: The Case for Caution

Laser surgery has been advocated for treatment of many laryngeal lesions. Although the CO2 laser has many advantages, its safe use requires special education of the surgeon and operating room team, and considerable surgical skill. Several dangers inherent in laser use for laryngeal surgery must be considered. These include vocal fold scarring secondary to thermal injury, loss of histopathologically important tissue through vaporization, airway fire and others. Laser-related complications must be considered whenever use of this instrument is contemplated.

Airway obstruction and high-frequency jet ventilation during laryngoscopy

High-frequency jet ventilation has been reported as an effective method of ventilation during laryngoscopy, but may expose the patient to the risks of barotrauma or alveolar hypoventilation. The aim of the study was to evaluate the determining factors of pulmonary complications under high-frequency jet ventilation in 83 patients undergoing laryngoscopy for upper airway cancer. Pulmonary distention was mainly influenced by upper airway obstruction score (p = .0001), while patients with chronic obstructive pulmonary disease (COPD) did not suffer from gas trapping. Impaired gas exchange was predicted by increased weight (p = .0001), smaller injector diameter (p = .02), and lower airway obstruction (p = .001). Hypercapnia occurred in both upper and lower airway obstruction, while hypoxemia was principally observed in COPD patients. Emphasis is placed on monitoring by pulse oximetry, end-expiratory pressure, and PCO2 measurement, especially in patients with obesity, COPD, or upper airway obstruction.