Laryngectomy – Anesthetic Considerations

Laryngectomy is a surgical removal of the larynx, most commonly performed for laryngeal carcinoma or severe airway compromise. This procedure permanently alters airway anatomy, requiring special anesthetic considerations, particularly in airway management, ventilation, and postoperative care.

1. Types of Laryngectomy

Type	Description	Airway Considerations
Partial Laryngectomy	Removal of part of the larynx, preserving voice function	Airway integrity is maintained; temporary tracheostomy may be needed
Supraglottic Laryngectomy	Removal of structures above the vocal cords	Risk of aspiration; temporary tracheostomy
Total Laryngectomy	Complete removal of the larynx	Permanent tracheostomy; airway and digestive tract are separated

2. Preoperative Considerations

A. Airway Assessment

• Risk of difficult airway due to tumor mass → Distorted anatomy.

• History of prior radiation therapy → Fibrosis, limited neck extension.

• Existing tracheostomy? → If present, it can be used for ventilation.

B. Pulmonary Evaluation

• Chronic smoking history → COPD, restrictive lung disease.

• Preoperative chest physiotherapy may be beneficial to optimize lung function.

C. Nutritional and Fluid Status

• Malnutrition is common due to dysphagia in laryngeal cancer.

• Albumin levels should be optimized to enhance healing.

D. Vocal Cord Function

• Assessment of vocal cord mobility before anesthesia to anticipate airway issues.

3. Intraoperative Anesthesia Considerations

A. Airway Management

• If no tracheostomy is present:

✅ Awake fiberoptic intubation is preferred to secure the airway.

✅ Elective tracheostomy may be done before induction to prevent airway collapse.

• If a tracheostomy is present:

✅ Use the existing tracheostomy tube for ventilation.

• Avoid nasal intubation (risk of tumor invasion or bleeding).

B. Anesthetic Technique

✅ General anesthesia with muscle relaxation is the preferred approach.

✅ TIVA (Total Intravenous Anesthesia) vs. volatile agents: Both are acceptable.

✅ Neuromuscular blockade: Succinylcholine is safe unless contraindicated.

C. Ventilation Considerations

✅ After total laryngectomy, ventilation is only possible via the tracheostomy.

✅ Avoid nitrous oxide if flap reconstruction is planned (prevents air expansion in tissues).

✅ Use humidified oxygen to prevent thick secretions.

D. Hemodynamic Management

✅ Surgery can lead to major blood loss, so adequate IV access and blood availability are necessary.

✅ Controlled hypotension may be used to reduce bleeding.

E. Monitoring

✅ Standard ASA monitoring (ECG, NIBP, SpO₂, EtCO₂).

✅ End-tidal CO₂ (ETCO₂) monitoring via tracheostomy or ETT.

4. Postoperative Care

A. Airway Management

✅ Total laryngectomy patients breathe exclusively through a tracheostomy.

✅ Adequate humidification via the tracheostomy is essential.

✅ Monitor for mucous plugging or crusting in the tracheostomy.

B. Pain Management

✅ Multimodal analgesia (paracetamol, NSAIDs, PCA opioids).

✅ Avoid excessive opioids due to respiratory depression risk.

C. Respiratory Care

✅ Chest physiotherapy and suctioning to prevent secretion retention.

✅ Monitor for mucous plugging in the tracheostomy.

D. Nutritional Support

✅ Enteral feeding via nasogastric tube or PEG until swallowing function is assessed.

✅ Total parenteral nutrition (TPN) may be needed for malnourished patients.

E. Postoperative Complications

✅ Hemorrhage – Risk of neck hematoma compressing the airway.

✅ Anastomotic leak – Can lead to infection and requires urgent intervention.

✅ Wound infection – More common in patients with previous radiation therapy.

MCQs on Laryngectomy

1. In a patient undergoing total laryngectomy, airway management involves:

A) Nasotracheal intubation

B) Oral intubation with rapid sequence induction

C) Elective tracheostomy with ventilation via tracheostomy tube

D) Awake fiberoptic nasal intubation

✅ Answer: C (Elective tracheostomy preferred for ventilation).

2. After total laryngectomy, the patient’s breathing occurs via:

A) Mouth and nose

B) Nasopharyngeal airway

C) Permanent tracheostomy

D) Laryngeal mask airway (LMA)

✅ Answer: C (Total laryngectomy results in a permanent tracheostomy).

3. Which of the following must be avoided in a patient undergoing free flap reconstruction after laryngectomy?

A) Sevoflurane

B) Nitrous oxide

C) Propofol

D) Fentanyl

✅ Answer: B (Nitrous oxide can expand air and cause flap ischemia).