Management of difficult airway in intratracheal tumor surgery

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Abstract

Background

Tracheal malignancies are usual victim of delay in diagnosis by virtue of their symptoms resembling asthma. Sometimes delayed diagnosis may lead to almost total airway obstruction. For difficult airways, not leaving any possibility of manipulation into neck region or endoscopic intervention, femorofemoral cardiopulmonary bypass can be a promising approach.

Case Presentation

We are presenting a case of tracheal adenoid cystic carcinoma (cylindroma) occupying about 90% of the tracheal lumen. It was successfully managed by surgical excision of mass by sternotomy and tracheotomy under femorofemoral cardiopulmonary bypass (CPB).

Conclusion

Any patient with recurrent respiratory symptoms should be evaluated by radiological and endoscopic means earlier to avoid delay in diagnosis of such conditions. Femorofemoral cardiopulmonary bypass is a relatively safe way of managing certain airway obstructions.

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Most cited references 8

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Adenoid cystic carcinoma of the airway: thirty-two-year experience.

Terje Hagen, S Keshavjee, Scott Pearson … (1996)

We have reviewed our experience in 38 patients with adenoid cystic carcinoma of the upper airway seen between 1963 and 1995. The mean age was 44.8 years (15 to 80 years) with a male/female ratio of 1:1.1. Thirty-two of the 38 patients were treated by resection and reconstruction (primary anastomosis 28; Marlex mesh prosthesis 4). Twenty-six of the 32 patients undergoing resection received adjuvant radiotherapy. Six patients with unresectable tumors were treated primarily with radiotherapy only. Pathologic examination revealed local invasion beyond the wall of the trachea in all patients. In a majority, microscopic extension was found in submucosal and perineural lymphatics, well beyond the grossly visible or palpable limits of the tumor. Lymphatic metastases were relatively uncommon, occurring in only five of 32 (19%) patients undergoing resection. Metachronous hematogenous metastases occurred in 17 of 38 patients (44%). Thirteen of these 38 patients (33%) had pulmonary metastases. Sixteen of 32 resections were complete and potentially curative. There were two deaths within 30 days of operation. The mean survival in the 14 patients undergoing complete resection was 9.8 years (12 months to 29 years). Sixteen of 32 resections were incomplete (residual tumor at the airway margin on final pathologic examination), with one operative death occurring in this group. The mean survival in the 15 surviving patients was 7.5 years (4 months to 21 years). Six patients were treated with primary radiation only and had a mean survival of 6.2 years (2 months to 14.3 years). In the patients with pulmonary metastases, mean survival was 37 months (4 months to 7 years) from the time of diagnosis of the pulmonary metastasis until their death. Adenoid cystic carcinoma of the upper airway is a rare tumor, which is locally invasive and frequently amenable to resection. Although late local recurrence after resection is a feature of this tumor (up to 29 years), excellent long-term palliation is commonly achieved after both complete and incomplete resection. There was a small difference in survival between patients having complete and incomplete resection. Long periods of control can be obtained with radiotherapy alone. The best results, in this series of patients, were obtained by resection. Adjuvant radiotherapy is assumed to favorably influence survival.

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Tracheal resection and reconstruction.

C Pinsonneault, Olivio F Donati, J Fortier (1999)

To review the literature on tracheal and carinal resection and reconstruction, and to report the general approach to these patients, as well as the general guidelines for the safe administration of anesthesia. The airway management is extensively reviewed. Articles obtained from a Medline search (1960 to October 1997; keywords: tracheal surgery, carinal surgery, airway management). Textbook literature including the bibliographies were also consulted. Benign or malignant tracheal and carinal pathology causing obstruction can be managed in several ways but resection and reconstruction are the treatment of choice for most patients with tracheal stenosis or tumour. Surgery of the trachea is a special endeavour where the airway is shared by the surgeon and the anesthesiologist. The principal anesthetic consideration is ventilation and oxygenation in the face of an open airway. Ventilation can be managed in different ways, including manual oxygen jet ventilation, high frequency jet ventilation, distal tracheal intubation, spontaneous ventilation, and cardiopulmonary bypass. The management of anesthesia for tracheal surgery presents many challenges to the anesthesiologist. Knowledge of the various techniques for airway management is crucial. Meticulous planning and communication between the anesthesia and surgical teams are mandatory for the safe and successful outcome of surgery for patients undergoing this procedure.

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The use of cardiopulmonary bypass during resection of locally advanced thoracic malignancies: a 10-year two-center experience.

Marzia Leacche, Raphael Bueno, Subroto Paul … (2004)

The use of cardiopulmonary bypass (CPB) for locally advanced thoracic malignancies is highly controversial. The purpose of this study was to document the techniques and results of CPB to facilitate the resection of complex thoracic malignancies and to identify common themes that provided for successful outcomes. This was a retrospective study that took place from January 1992 to September 2002. Fourteen consecutive patients (median age, 59 years; age range, 18 to 69 years; seven men and seven women) underwent CPB during the resection of locally advanced thoracic malignancies at two Boston hospitals. CPB was planned in 8 of 14 patients (57%) with centrally located tumors, while 6 of 14 patients (43%) required emergent institution of CPB due to injury of the superior vena cava (2 patients), inferior vena cava (2 patients), or pulmonary artery (2 patients). Complete microscopic resection was achieved in 12 of 14 patients (86%). The operative mortality rate was 1 of 14 patients (7%) due to pulmonary embolism (ie, the elective group). The median ICU and hospital lengths of stay were 5 and 9 days, respectively. The overall 1-year, 3-year, and 5-year survival rates were 57%, 36%, and 21%, respectively. The planned use of CPB to facilitate complete resection of thoracic malignancies should be considered only after careful patient selection. The availability of CPB also provides a safety net in the event of injury to vascular structures during tumor resection.

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Author and article information

Journal

Journal ID (nlm-ta): BMC Ear Nose Throat Disord

Title: BMC Ear, Nose and Throat Disorders

Publisher: BioMed Central (London )

ISSN (Electronic): 1472-6815

Publication date Collection: 2005

Publication date (Electronic): 7 June 2005

Volume: 5

Page: 4

Affiliations

[1 ]Neuro-otology Unit, Department of Neuro-surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareily Road, Lucknow (Uttar Pradesh) – 226 014, India

[2 ]Department of Anesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareily Road, Lucknow (Uttar Pradesh) – 226 014, India

[3 ]Department of Cardiovascular & Thoracic Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareily Road, Lucknow (Uttar Pradesh) – 226 014, India

Article

Publisher ID: 1472-6815-5-4

DOI: 10.1186/1472-6815-5-4

PMC ID: 1180430

PubMed ID: 15941480

SO-VID: f1c7c935-ee82-4bad-aea1-7a17ce33e7c0

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Management of difficult airway in intratracheal tumor surgery

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Abstract

Background

Case Presentation

Conclusion

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Most cited references 8

Adenoid cystic carcinoma of the airway: thirty-two-year experience.

Tracheal resection and reconstruction.

The use of cardiopulmonary bypass during resection of locally advanced thoracic malignancies: a 10-year two-center experience.

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