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Carcinoma buccal mucosa Moderator: Dr. Bhalla Presenter: Dr. Dipal

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Presentation on theme: "Carcinoma buccal mucosa Moderator: Dr. Bhalla Presenter: Dr. Dipal"— Presentation transcript:

1 Carcinoma buccal mucosa Moderator: Dr. Bhalla Presenter: Dr. Dipal
Case presentation Carcinoma buccal mucosa Moderator: Dr. Bhalla Presenter: Dr. Dipal

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 submandibular region – 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

CVS: Apex beat 5th intercostals space S1, S2 normal No murmurs RESPIRATORY: Trachea midline B/L Air entry equal No added sounds

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:: Bilirubin: 0.7 TP/A/G: 8.3/4.5/3.8 OT/PT: 31/20
Hb: 12.9 gm% TLC: 14500 PLT ct: 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 buccal mucosa 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
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
MMP class Cormack and Lehane grade Grade 1 Grade 2 Grade 3 Grade 4 Class I (73%) 59% 14% - Class II (19%) 5.7% 6.7% 4.7% 1.9% Class III & IV (8%) 0.5% 5% 2.5% 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 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 Difficulty None Moderate Severe

42 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


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

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

46 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

47 Statistical Significance of Bedside Predictors
Diagnostic test Sensitivity Specificity MMP class 49% 86% TMD 20% 94% Sternomental distance 62% 82% Mouth opening 22% 97% Wilson risk score 46% 89% MMP + TMD 56%

48 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

49 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

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

51 ASA task force on management of DA
Strategy depending on Anticipated surgery Patient condition Skill & preference of anaesthesiologist 4 basic problems 3 basic management choices Primary approach Alternative approach Exhaled CO2 to confirm tracheal intubation


53 LMA in ASA DA algorithm

54 ASA task force on management of DA
Strategy for extubation of DA Awake? Adverse impacts on ventilation Further A/w management plan Guide for reintubation Follow up

55 Limitations of ASA guidelines
Open ended, wide choice of techniques Emphasis on prediction of difficult airway No stratification of available a/w devices No expression of strength of recommendation

56 DAS guidelines (Anaesthesia.2004.59)
Management of un-anticipated difficult intubation in an adult non-obstetric patient Paediatric, obstetric patients & patients with upper a/w obstruction excluded Flow charts based on series of plans Careful planning with backup plans Maintenance of oxygenation takes priority Seek the best assistance available




60 SIAARTI guidelines (Minerva Anesthesiol 2005;71:617-57)
Doesn’t apply to paediatric patients Defines strength of expressed recommendation Defines difficult a/w control, ventilation, intubation & laryngoscopy Difficulty prediction (severe/borderline) Devices managament Mandatory Other devices, available upon request Other mentions

61 SIAARTI guidelines (Planning in unpredicted difficult a/w)
Correct position Alternative options (blade/stylet/introducer/ magill’s) Oxygenation is mandatory Urgency/ emergency of procedure Elective sx Deferrable urgent sx Emergent sx

62 SIAARTI guidelines (Planning in unpredicted difficult a/w)
Immediate withdrawal in CL – IIIe & IV Preliminary knowledge of alternative devices, training in FOI Blind intubation via extraglottic devices not recommended in emergency/ after repeated attempts Use of fiberscope in emergency situations is not recommended

63 SIAARTI guidelines (Planning in predicted difficult a/w)
Strategy depends upon Surgery deferrability Risk of vomiting Skill of anaesthesist Available instrumentation Patient cooperation Grade of predicted difficulty

64 SIAARTI guidelines (Planning in predicted difficult a/w)
Predicted severe DA Maintain consciousness, spont. Breathing 1st choice – awake FOI Surgery under RA not recommended Intubation under direct vision Retrograde intubation as an alternative to FOI

65 SIAARTI guidelines (Planning in predicted difficult a/w)
Predicted severe DA Anaesthesia can be induced Preoxygenation & ventilability evaluation Laryngoscopy grading influences further choice CVCI 1st choice- cricothyrotomy Surgeons intervention as an exception

66 DGAI guidelines (Anasth Intensiv Med Mar2004;45)
4 stage scheme

67 DGAI guidelines Decission to more invasive approach to be made in stages

68 DGAI guidelines Strategy aimed at most minimal invasiveness

69 DGAI guidelines

70 Extubation strategy Cuff leak test Performed in a spontaneously ventilating patient at risk of obstruction after extubation Circuit disconnected  occlusion of ETT end and deflation of cuff  ability to breath around the ETT Conventional awake extubation Extubation in a deep plane of anaesthesia followed by placement of LMA to decrease the risk of laryngospasm Extubation over a fibreoptic bronchoscope Endotracheal ventilation and exchange catheters e.g. Cook’s airway exchange catheter Tracheal tube exchanger

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