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Case presentation

Case presentation. Carcinoma buccal mucosa Moderator: Dr. Bhalla Presenter: Dr. Dipal. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. CHIEF COMPLAINTS:. 30 yr/ M/ 55kg Resident of U.P. Ulcer over Rt buccal mucosa – 5 months Swelling over Rt cheek – 4months

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  1. Case presentation Carcinoma buccal mucosa Moderator: Dr. Bhalla Presenter: Dr. Dipal www.anaesthesia.co.in anaesthesia.co.in@gmail.com

  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 submandibularregion – 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:: • Hb: 12.9 gm% • TLC: 14500 • PLT ct: 369000 • 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 buccalmucosa 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 Difficult airway: • 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 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 3-3-2 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. 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

  42. Predictors of Difficult Mask Ventilation • B: Beard • O: BMI > 26 kg/m2 • N: Edentulous • E: Age > 55 years • S: History of snoring Langeronet al, Anesthesiology, November 2006 (bones)

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

  44. 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

  45. Statistical Significance of Bedside Predictors

  46. 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

  47. 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

  48. ASA task force on management of DA 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 • Basic preparation • Inform • Ascertain help • Preoxygenation • Supplemental oxygenation throughout

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