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Multidisciplinary difficult airway challenges: Perioperative management of glottic and supraglottic tumors

      Carcinomas of the larynx are common and require multidisciplinary perioperative management, with particularly excellent communication between the surgeon and anesthesiologist. Early preoperative assessment allows for optimization, prehabilitation and advanced imaging in cases who present without respiratory compromise. On arrival for surgery, thorough airway examination including preoperative endoscopic airway assessment under topical anesthesia and airway ultrasound will inform planning for airway management. The fundamental decision between awake tracheal intubation or awake tracheostomy, and intubation after induction of anesthesia should be made as a team, with strategies for failure (such as rigid bronchoscopy or emergency surgical airway) clearly defined, and staff and equipment present. Balanced total intravenous anesthesia with target-controlled infusions allow good analgesia and smooth emergence. Admission to a postanesthesia high care environment is advisable.

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      References

        • Coca-Martinez M.
        • Barberan-Garcia A.
        • Risco R.
        Fit for surgery? Evidence supporting prehabilitation programs.
        Br J Anaesth. 2018; 120: 1429
        • Hanna K.
        • Ditillo M.
        • Joseph B.
        The role of frailty and prehabilitation in surgery.
        Curr Opin Crit Care. 2019; 25: 717-722
        • Levett D.Z.
        • Grocott M.P.
        Cardiopulmonary exercise testing, prehabilitation, and enhanced recovery after surgery (ERAS).
        Can J Anaesth. 2015; 62: 131-142
        • Lopez Rodriguez-Arias F.
        • Sanchez-Guillen L.
        • Armananzas Ruiz L.I.
        • et al.
        A narrative review about prehabilitation in surgery: current situation and future perspectives.
        Cir Esp. 2020; 98 (Epub 2020 Jan 25): 178-186https://doi.org/10.1016/j.ciresp.2019.11.005
        • Sanchez-Lorente D.
        • Navarro-Ripoll R.
        • Guzman R.
        • et al.
        Prehabilitation in thoracic surgery.
        J Thorac Dis. 2018; 10: S2593-SS600
        • Stokes S.M.
        • Wakeam E.
        • Antonoff M.B.
        • et al.
        Optimizing health before elective thoracic surgery: systematic review of modifiable risk factors and opportunities for health services research.
        J Thorac Dis. 2019; 11: S537-SS54
        • Templeton R.
        • Greenhalgh D.
        Preoperative rehabilitation for thoracic surgery.
        Curr Opin Anaesthesiol. 2019; 32: 23-28
        • Wynter-Blyth V.
        • Moorthy K.
        Prehabilitation: preparing patients for surgery.
        BMJ. 2017; 358: j3702
        • Slonimsky E.
        Laryngeal imaging.
        Oper Tech Otolaryngol. 2019; 30: 237-242
        • Ahmad I.
        • Keane O.
        • Muldoon S.
        Enhancing airway assessment of patients with head and neck pathology using virtual endoscopy.
        Indian J Anaesth. 2017; 61: 782-786
        • Gallivan R.P.
        • Nguyen T.H.
        • Armstrong W.B.
        Head and neck computed tomography virtual endoscopy: evaluation of a new imaging technique.
        Laryngoscope. 1999; 109: 1570-1579
        • Burke A.J.
        • Vining D.J.
        • McGuirt Jr., W.F.
        • et al.
        Evaluation of airway obstruction using virtual endoscopy.
        Laryngoscope. 2000; 110: 23-29
        • Thomas B.P.
        • Strother M.K.
        • Donnelly E.F.
        CT virtual endoscopy in the evaluation of large airway disease: review.
        AJR Am J Roentgenol. 2009; 192 (quiz S1-3): S20-S30
        • Ahmad I.
        • Millhoff B.
        • John M.
        Virtual endoscopy–a new assessment tool in difficult airway management.
        J Clin Anesth. 2015; 27: 508-513
        • El-Boghdadly K.
        • Onwochei D.N.
        • Millhoff B.
        The effect of virtual endoscopy on diagnostic accuracy and airway management strategies in patients with head and neck pathology: a prospective cohort study.
        Can J Anaesth. 2017; 64: 1101-1110
      1. Hofmeyr R.Airway Topicalisation: How to make the GSH mix. 2017. Available at: https://openairway.org/airway-topicalisation-how-to-make-the-gsh-mix/Accessed February 1, 2020

        • Law J.A.
        • Duggan L.V.
        The airway assessment has come of age-or has it?.
        Anaesthesia. 2019; 74: 834-838
        • Law J.A.
        • Morris I.R.
        • Malpas G.
        Obstructing pathology of the upper airway in a post-NAP4 world: time to wake up to its optimal management.
        Can J Anaesth. 2017; 64: 1087-1097
        • Rosenblatt W.
        • Ianus A.I.
        • Sukhupragarn W.
        Preoperative endoscopic airway examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation.
        Anesth Analg. 2011; 112: 602-607
        • McAvoy J.
        • Ewing T.
        • Nekhendzy V.
        The value of preoperative endoscopic airway examination in complex airway management of a patient with supraglottic cancer.
        Head Neck Anesth. 2019; 3
        • Rosenblatt W.H.
        Preoperative endoscopic airway examination.
        in: Abdelmalak B Doyle J Anesthesia for Otolaryngologic Surgery. Cambridge University Press, Cambridge2012: 50-57
        • Moorthy S.S.
        • Gupta S.
        • Laurent B.
        Management of airway in patients with laryngeal tumors.
        J Clin Anesth. 2005; 17: 604-609
        • Alessandri F.
        • Antenucci G.
        • Piervincenzi E.
        • et al.
        Ultrasound as a new tool in the assessment of airway difficulties.
        Eur J Anaesthesiol. 2019;
        • Athanassoglou V.
        • Hughes-Jones H.
        • Hadjipavlou G.
        Depth to the airway lumen at the level of the cricothyroid membrane measured by ultrasound.
        Acta Anaesthesiol Scand. 2020; 64: 48-52
        • Koundal V.
        • Rana S.
        • Thakur R.
        The usefulness of point of care ultrasound (POCUS) in preanaesthetic airway assessment.
        Indian J Anaesth. 2019; 63: 1022-1028
        • You-Ten K.E.
        • Siddiqui N.
        • Teoh W.H.
        Point-of-care ultrasound (POCUS) of the upper airway.
        Can J Anaesth. 2018; 65: 473-484
        • Kristensen M.S.
        • Teoh W.H.
        • Rudolph S.S.
        • et al.
        Structured approach to ultrasound-guided identification of the cricothyroid membrane: a randomized comparison with the palpation method in the morbidly obese.
        Br J Anaesth. 2015; 114: 1003-1004
        • Kristensen M.S.
        • Teoh W.H.
        • Rudolph S.S.
        A randomised cross-over comparison of the transverse and longitudinal techniques for ultrasound-guided identification of the cricothyroid membrane in morbidly obese subjects.
        Anaesthesia. 2016; 71: 675-683
        • Krause M.
        • Khatibi B.
        • Sztain J.F.
        Ultrasound-guided airway blocks using a curvilinear probe.
        J Clin Anesth. 2016; 33: 408-412
        • Mason R.A.
        • Fielder C.P.
        The obstructed airway in head and neck surgery.
        Anaesthesia. 1999; 54: 625-628
        • Anaesthetists RCo
        NAP4: Major Complications of Airway Management in the United Kingdom.
        2011 (London)
        • Wong P.
        • Wong J.
        • Mok M.U.
        Anaesthetic management of acute airway obstruction.
        Singapore Med J. 2016; 57: 110-117
        • Frerk C.
        • Mitchell V.S.
        • McNarry A.F.
        • et al.
        Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults.
        Br J Anaesth. 2015; 115: 827-848
        • Chrimes N.
        The Vortex: a universal 'high-acuity implementation tool' for emergency airway management.
        Br J Anaesth. 2016; 117: i20-ii7
        • Chrimes N.C.
        The Vortex: striving for simplicity, context independence and teamwork in an airway cognitive tool.
        Br J Anaesth. 2015; 115: 148-149
        • Kingma K.
        • Hofmeyr R.
        • Zeng I.S.
        Comparison of four methods of endotracheal tube passage in simulated airways: There is room for improved techniques.
        Emerg Med Australas. 2017; 29: 650-657
        • Driver B.E.
        • Prekker M.E.
        • Klein L.R.
        • et al.
        Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: A randomized clinical trial.
        JAMA. 2018; 319: 2179-2189
        • Ahmad I.
        • El-Boghdadly K.
        • Bhagrath R.
        • et al.
        Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.
        Anaesthesia. 2019;
        • Alhomary M.
        • Ramadan E.
        • Curran E.
        Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: a systematic review and meta-analysis.
        Anaesthesia. 2018; 73: 1151-1161
        • Law J.A.
        • Morris I.R.
        • Brousseau P.A.
        The incidence, success rate, and complications of awake tracheal intubation in 1,554 patients over 12 years: an historical cohort study.
        Can J Anaesth. 2015; 62: 736-744
        • Badiger S.
        • John M.
        • Fearnley R.A.
        Optimizing oxygenation and intubation conditions during awake fibre-optic intubation using a high-flow nasal oxygen-delivery system.
        Br J Anaesth. 2015; 115: 629-632
        • Cook T.M.
        • Woodall N.
        • Frerk C.
        • Fourth National Audit P
        Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.
        Br J Anaesth. 2011; 106: 617-631
        • Cormack R.S.
        • Lehane J.
        Difficult tracheal intubation in obstetrics.
        Anaesthesia. 1984; 39: 1105-1111
        • Yentis S.M.
        • Lee D.J.
        Evaluation of an improved scoring system for the grading of direct laryngoscopy.
        Anaesthesia. 1998; 53: 1041-1044