Head and neck surgery in a tertiary centre: Predictors of difficult airway and anaesthetic management

Abstract

Introduction: The management of head and neck surgical patients is associated with increased morbidity and mortality, and so anticipating the difficult airway is important. Methods: We undertook a prospective survey on consecutive adult patients scheduled on the elective operating lists of four head and neck consultant surgeons. Data were collected over a 36 month period. Data included: patient characteristics; routine predictors of difficulty in airway management (bedside tests of the airway, a history of previous surgery or radiotherapy and the presence of airway symptoms); laryngoscopy grade; method of anaesthesia and airway management; and any airway complications arising during induction of anaesthesia and extubation. Results: The 'study' group consisted of 818 patients. The 'direct laryngoscopy' group contained 674 patients, that is, patients who had direct laryngoscopy and could therefore be classified as easy or difficult intubation. The prevalence of difficult intubation was 12.6%. Factors or tests that were statistically significantly associated with difficult intubation were: history of difficult airway; previous head or neck radiotherapy treatment; presence of airway symptoms; presence of moderate or severe limited neck movement; and short interdental distance. The sensitivity, specificity and positive predictive values were: history of difficult airway 16.5%, 98.6% and 63.6%; previous radiotherapy 12.9%, 96.6% and 35.5%; airway symptoms 42.9%, 69.6% and 15.9%; moderate/ severe neck limitation 16.7%, 97.2% and 46.7%; Mallampati score 3 or 4, 38.8%, 83.8% and 25.8%; and interdental distance 9.4%, 98.8% and 53.3%, respectively. The Bonfils intubation fibrescope was the most commonly used indirect laryngoscopy device (63.9% of all such cases). Twenty-six patients (3.2%) had complications during their initial airway management after induction of anaesthesia. There was one case of 'cannot intubate, cannot oxygenate', which required an emergency tracheostomy. Conclusion:The prevalence of difficult intubation in head and neck surgical patients was higher than in the general population, but predictive tests for difficult intubation have poor to moderate value. In our study, rates of difficult face mask ventilation, failed intubation and complications during induction and extubation were low. However, serious morbidity, although rare, can still be encountered. Head and neck surgical patients can be managed safely in a tertiary centre where there is appropriate surgical and anaesthetic expertise in managing difficult airways.

Are Bedside Predictors of Difficult Intubation Really True Indicators in Head and Neck Cancer Patients?

“…But though TMD was less in 23.33% patients but on univariate and multivariate regression analysis even TMD did not show significant correlation. Similarly, in a study done by Patrick Wong et al 10 on 818 patients, difficult intubation occurred in 12.6% of patients in which they have included both benign and malignant ENT cases and have used CL>=3 as measure of DI. They found that bed side predictors of DI yielded poor sensitivity.…”

Successful use of C-MAC® video laryngoscope for unexpected severe airway narrowing during anesthesia induction in a patient with a moderate-sized laryngeal tumor

“…However, dyspnea disappeared after admission with steroid treatment. Wong et al 3 have studied possible predictive factors by analyzing correlations between various clinical aspects and outcomes of difficult airway in patients with periglottic tumors. In their study, various kinds of airway devices such as conventional direct laryngoscope, videolaryngoscope, optical stylet, and fiberoptic bronchoscopes were used.…”

“…12 This new tool has given various aids in solving difficult airway situations. 3,13 It has also replaced the need of using awake fiberoptic bronchoscopy or surgical airways. 12,13 There is good evidence of using videolaryngoscope in priority in situations of difficult airways.…”

“…Furthermore, laryngeal masses could show varying clinical features according to their variable durations of mass growth, locations, sizes, and radiation history, adding challenges to airway management. 2,3 Thus, anesthesiologists and surgeons as perioperative physicians should be highly familiar with diverse manifestations of this condition during induction. 4 At present, airway management algorithms for unexpected and difficult airway situations during induction of healthy patients have been established.…”

First-Pass Success of Tracheal Intubation With Videolaryngoscopy in Head and Neck Cancer Patients: A Registry-Based Retrospective Cohort Study

“…Oral cancer is ranked as the sixth most common cancer worldwide [ 1 ] and 40% occur in Southeast Asian countries (India, Sri Lanka, Bangladesh, and Pakistan) [ 2 ]. The incidence of difficult intubation is higher in patients with ear, nose, and throat malignancies than in the general surgical population (15.75% vs. 2.5%) [ 3 , 4 ].…”