Microlaryngeal surgery

Microlaryngeal surgery, surgery, medicine

1. 1
Tracheostomy
and
anaesthesia
for
Microlaryngeal surgery
Dr Poonam Bhadoria
MD
Professor
Department of anaesthesia
Maulana Azad medical college & Lok Nayak hospital
New Delhi-110002

2. 2
DDefinition
It'sasurgicalincisionintothetrachea for
establishingairway.
AAtubeisplacedinthetracheajustbelow2
nd
and3
rd
trachealringsbypassingtheepiglottis.
Maybe highin2
nd
trachealring,
midin3
rd
to4
th
tracheal
lowtrachealring5
th
to6
th
“Bettertoooftenthantoolate”

3. 3
History
AreferencewasmadeinaHindumedicinetext
writtenin2000BC
In15
th
century,Prasovalareported1stsuccessful
tracheostomy
In1799–GeorgeWashingtondiedofanUAO.
From1830sto1930:emergencyprocedurein
childrenwithdiphtheria.
In1907–ChevalierJacksonwroteabookand
standardizedthetechnique.
Gallowayexpandeditsuseintreatmentofparalysis
andmanagementofsecretions.
Inmid1980s-briefpopularityofmini-tracheostomy.

4. 4
Anesthesiologist?
Otolaryngologist?
Paramedic personnel?

5. 5
CRICOTHYROTOMY
whether to perform it?
Suspicion of acute upper airway problem
Worsening stridor
Reducing self-ventilation

6. 6
CRICOTHYRODOTOMY
how to perform it?
Extend the neck
Palpate the cricoid arch : enter just above it
Enter larynx just above the cricoid
Midline incision using either blade or IV
cannula
Knife may be rotated through 90
o
to keep the
incision open
Convert to formal tracheostomy as soon as
possible.

7. 7
ANATOMY OF LARYNX
Thelarynxliesinthefrontofhypopharynxopposite
the3
rd
–6
th
cervicalvertebrae.
Cartilages
-Unpaired :thyroid cricoid, epiglottis
-Paired :arytenoid, comiculate,
cuneiform

8. 8
STEPS OF SURGERY
●Thedegreeofurgencyinestablishing
tracheostomywilldeterminethemethodbutpreference
shouldalwaysbegiventoelectiveprocedure.
●Securetheairwaywithminimumtimeand
complications.
1.CONSENT
2.PREMEDICATION
3.POSITION
supine with a pillow under shoulder to extend the neck
to bring the trachea forward.
4.ANAESTHESIA
Local anaesthesia with 1-2% lignocaine with
epinephrine in line of incision.
.

9. 9
EMERGENCY ELECTIVE
1.Noorlocalanaesthesia 1.LA/GAwithMAC
2.Consent–mayormaynotbe 2.Consent-must
3.Nopre-oppreparation 3.Pre-oppreparation
careregimencontrolof
medicalproblem
4. Vertical incision with gives rapid
access
4.Horizontalincision
5. Prime importance is securing
airway than bleeding
5.Controlofbleedingprior
tosecuringairway.

10. 10
STEPS
1)Cleaning & draping with full aseptic
precautions
2)Inspection and palpation of the neck to assess
laryngotracheal anatomy.
3)Collar incision 2 cm > suprasternal notch.
4)Tissues are directed & strap muscles are
separated
5)Thyroid & isthmus is displaced upwards
continues

11. 11
6)Tracheaisfixedwithahookandopenedwitha
horizontalincisionin3
rd
trachealspacewhichis
convertedintoacircularopeningbyexcisingapart
ofonetrachealring.
7)Inchildren-verticalincisionintracheaandinsert
twostaysuture.
8)NoLAintrachea(coughreflex)orparatracheal
gutter(recurrentlaryngealnerve).
9)Inserttube.
10)Skinincisionshouldnotbesuturedorpacked
tightly.
11)Dressing.

12. 12

13. 13

14. 14

15. 15
INDICATIONS FOR TRACHEOSTOMY
the five “Rs”
1.RespiratoryObstruction
congenital,traumaticinfection,neoplasm,foreign
body,bilateralabductorpalsy
2.Respiratoryfailure
topreventaspirationinunconsciouspatient
3.Respiratoryparalysis
neurologicaldisease,prolongedcoma,spinalcord
injury
4.Removalofretainedsecretions
Inabilitytocough(polio,GBS)
5.Reductionofdeadspace
6.Plannedtracheostomy
failedintubation,CaLx,burncontracture

16. 16
PHYSIOLOGICAL EFFECTS
Decrease in dead space by 100 ml.
Decrease work of breathing
Decrease in airway resistance
Prevent speech.
Prevents humidification and warming of inspired air
Loss of cilia, mucous secretions result in squamous
metaplasia
Interfere with elevation of larynx during swallowing.
Increase risk of chest infection.

17. 17
TYPES OF TRACHEOSTOMY TUBES
•Metal (Jackson), Non-metallic or plastic (Portex)
•Cuffed or uncuffed
•Single cannula or Double cannula
•Fenestrated (for speaking) or non-fenestrated
•Disposable and permanent
•Special Tubes
-Durham's tube for obese patient which has
adjustable flange
-Celebes –double cuffed
-Shiley (long term PVC for children)

18. 18
COMPLICATIONS
IMMEDIATE (0.1-22.9%)
Haemorage,aspirationofblood,pneumothorax,
localdamage,airembolism.
POST-OP(withinIstfewhrs-fewdays,0-37%)
Hemorrhage,tubedisplacement,respiratory
obstruction,localwoundinfection,granulation
tracheatiswithcrusting, tracheobronchitits,
atelactasis,,lung abscess, subcutaneous
andmediastinalemphysema
continues
Apnoea
&
Cardiac
arrest

19. 19
LONGTERM(forweeks-months,01.9%)
Haemorage, tracheomalacia,tracheal
stenosis,TO fistula,transcutaneous
fistula,hoarseness, dysphagia,
incoordinationofswallowingreflex,
problemofdecanulation,corrosion
oftracheostomytube,tracheostomy
scar

20. 20
POST OP TRACHEOSTOMY CARE
Constant supervision
Suction
Change of Tracheostomy Tube
Prevention of crusting (Humidification)
Proper stabilization
Care of inflatable cuff
Breathing exercises
Dressings
Nursing

21. 21
FUNCTIONS Of TRACHEOSTOMY
Alternative pathway for breathing
Improves alveolar ventilation
Protects the airway
Permits removal of secretions
Permits adequate ventilation
To administer anaesthesia

22. 22
ADVANTAGES IN ICU
Lower doses of sedation
Preservation of cough reflex
More efficient pulmonary toilet
Reduced duration of ventilation
Less laryngeal trauma

23. 23
COMPLICATIONS
ASSOCIATEDWITH SUCTIONING
Hypoxemia, dysarrhythmias, hypotension,
cardiac arrest
Atelactasis or lung collapse
Mucosal damage
Bronchospasm
Tracheobronchial bacterial growth

24. *How to prevent these complications?
1.Followa septic precautions.
2.Suction time <15 Sec.
3.<1/3 int. diam. Of suction catheter.
4.Vacuum Pr. 80-120mmHg.

25. 25
EMERGENCY EQUIPMENT TO BE KEPT AT
BEDSIDE
Suction apparatus
Sterile catheter
10 ml. Syringe for cuff inflation and deflation
Oxygen equipment
Ambu Bag
Sterile gloves, pair of dilators and seizers
Spare tracheostomy tube and ET
Wright’s spirometer

26. 26
PROBLEMS DURING DECANULATION
Because of tracheal edema or subglotic stenosis.
Persistence of condition for which tracheostomy was
done.
Obstructing granulations around and below the stoma.
Tracheomalacia
Incurved tracheal wall
Psychological dependence
Ventilator dependence

27. 27
PRINCIPLESOFDECANNULATION
•Tubeiscorkedoffforincreasingperiods
•Self-ventilatingforatleastonefullnight
•Nofurtherneedfortrachealsuction
•Removetube;plugtracheostomysite.
•Tubesizereducedbeforedecanulation

28. 28
ABG should be normal.
Depends on duration of Tracheostomy
<2 weeks
uncuffed-plug-watch 24 hours –remove the
tube and close the stoma
2-6 weeks
either immediate or gradual
>6 weeks
gradually to smaller size every 48 hours till
<size 5. TT removed, stoma left to heal by
granulation

29. 29
LIMITATION OF PERMANENT
TRACHEOSTOMY
Swimming
Climbing stairs
Heavy exercise
Can speak aloud

30. 30
PERCUTANEOUS TRACHEOSTOMY
Seldinger puncture of tracheal wall
Pass dilators over the guide wire
Insert lubricated tube
Variants: one-stage tracheal spreader,
endoscopic control

31. 31
ADVANTAGES OFPERCUTANEOUS
TRACHEOSTOMY IN ICU
No need to book OT time
No patient transport hazards
Comparable complication rates to open
tracheostomy

32. 32
CONTRAINDICATIONS
Children
Bleeding diathesis
Previous Surgery
Infection
Enlarged thyroid

33. 33
EQUIPMENT FOR PERCU. TRACHEOSTOMY
Scalpel
14Gintravenousneedleandcannula
10ml.syringe
FlexibleTeflon-coatedguidewire
Plasticdilator
Pairoftrachealdilatingforceps
Tracheostomytubewithahollowobturatortoslide
overtheguidewire.
Maintain100%O
2withmonitoringSPO
2,capno,ECG,
BP

34. 34

35. 35
MICROLARYNGEAL SURGERY
GOALS
Clear view
Immobile field
Sufficient space to work
PRESENTING COMPLAINTS OF
Hoarseness,
stridor
associated haemoptysis

36. 36
ANAESTHETIC CONCERNS (MLS)
Protection to trachea
Ensure good ventilation & oxygenation
Minimize secretions and reflexes
Rapid awakening & return of protective airway
reflexes

37. 37
PREOP. CONSIDERATIONS (MLS)
-Airway evaluation for TYPE OF LESION
(95% ant. & 5% post.)
-I/L & D/L (laryngeal inlet), CT, MRI
-Discuss with surgeon for SIZE OF TUMOUR
-Review on table
-Preoxygenation
-Glycopyrrolate 0.2-0.3mg IM

38. 38
VENTILATION & OXYGENATION
A).ETT–5mmID,longwithstandardcuff
(Microlaryngealtube)/Mallincordtcritical
carelowpressurehighvolume tube
Control ventilation-advantages:
-prevent aspiration
-maintain inhalation anaesthesia
-monitor ETCO
2

39. 39
Alternatives
(balanced technique-injector below vocal folds/lx)
B). Jet ventilation
ETT not required
Unobstructed view (profound messeter relax)
Alignment of laryngoscope & tracheal axis.
(pneumatic knife)
Full relaxation of V.C.
Free egress of gas
Monitor chest wall motion
continues

40. 40
Ventilatory rate –6-7 bpm at 30-50 PSI I/E 1.5:6
sec (Saunder’s jet injector)
Cuffed Carden tube.
Contraindicated in children, obese & bullous
emphysema.
Risks -barotrauma, stomach dilatation, forcing
of blood & tumour in lungs, pneumothorax,
hypotension.
C).Intermittent ETT and apneic period.
D).HFPPV, less risk of barotrauma. (80-300/min)

41. 41
Reflex responses :-HT, tachycardia, arrhythmia
-Use :I/V or topical lignocaine,
-I/V fentanyl, esmolol
Anaesthesia:-Propofol,fentanyl,
-tropicalanaesthesiaoflarynx,
-appropriatemusclerelaxation.
-Ensure adequate depth

42. 42
Monitoring : ECG, BP, Oximetry,
ETCO2
Post op. Risk :-MI or Ischemia 1.5-4%
-laryngospasm,
-laryngeal edema
-strider
-restlessness
(hypoxia, pain)

43. 43
Microscopic ear surgery
Goal: relatively bloodless field.
Methods:
-placing patients in 15
O
head up position
-vasodilators e.g. SNP, trimetaphan
-NTG drip
-controlled ventilation with VA
-propofol infusion (100µg/kg/min)
-fentanyl bolus (1-3µg/min)
-avoid inadvertent PEEP
-balance the risk/benefits

44. 44
LASERS AND ANAESTHESIA
Laser :Light amplification by stimulated
emission of radiation
By Einstein in 1917
Aggregation of PHOTONS with intense energy
Useful tool in modern surgery
First used in 1960-as Ruby laser
First used in medicine in 1964
First use in OT in 1970

45. 45
Laserbeamisintenselight,emittingidentical,
coherent,excitedphotonsinonedirection.
Consistsofpowersupply,lasingmedium&
opticalcavity.
Beamfocusedtosmallspot-precisecontrolled
coagulation,
Incisionorvaporarizationoftissue.

46. 46
TYPES:Solid, gas and liquid
Solid -Ruby, YAG & Dyed
Gas-CO2 Argon Krypton, Excimer
Neodymium : YAG
–Invisible near infra red
–Deeper tissue penetration & haemeostasis
–Can be transmitted via fibreoptics tubes
–Better absorbed by pigmented tissue
(hemangioma)

47. 47
CO2 laser
-Invisible infra red light
-Absorbed by tissue water
-Preciseincisionindependentoftissue
colourwithminimaldamageto
adjacenttissue
-suitableforvocalcord&laryngealsurgery
(10Wpowerwith0.1secpulses&asmall
spot)

48. 48
LASERHAZARDS
Tostaffandpatient
Misdirected-burn
Eyesarevulnerable
CO2–cornealburn
Fire&explosion(thermaleffect)
continues…

49. 49
Ignitionofinflammablematerials
ETT,breathingcircuits,drapes
Prep.solutions,lubricants&appliances
Atmosphericcontaminationswithsmoke&
plume(fine),particulateproductof
combustionduetotissuevaporizationby
laser

50. 50
SAFETY CONSIDERATIONS
OTwarningsignforlaseruse.
RestrictentryintoOT
Wearprotectiveeyeglasses(wavelength
specific).
Avoidflammablematerials(drapes,plastic
tubes,adhesivesetc.).
Patient'seyes–tapedclosed&coverwithwet
pads(CO
2laser),protectionglass–Nd:YAG
laser.
Wettowelstodrape.
continues…

51. 51
Competent personnel for equipment
use
Avoid misdirection of beam
Avoid ETT in short procedures use
venturi
Use fire proof tubes with saline filled
cuffs
Cover visible cuff area with moist
cotton pledgets
Ready bucket of clean water for
dipping the tube
Smoke evacuators at surgical site

52. 52
SPECIAL ETT & PROTECTION
Wrapping with wet muslin, dental acrylic
coating
(disadvantage: mucosal trauma)
Wrapping with metalised foil tape (CO
2laser)
(Aluminum, copper, plastic + metal)
Solid copper foil or aluminum (3m)
No.425/423)
(Protect from Nd:YAG laser for 60
sec)
Cuffs remain unprotected –fill them with
saline

53. 53
FDA APPROVED –MATERIAL & ETT
Merocel laser guard(tube wrap)
(Metal foil with sponge surface)
Xoned laser shield tube for CO2 laser
(Silicone with outer aluminum powder
coating)
Laser shield II –silicone tube with cuff

54. 54
METAL ENDOTRACHEAL TUBE
Norton’s
Stainlesssteelspiralcoilwithoutcuff
(Wallsnotairtight)
Laserflextube
Airtightstainlesssteelspiralwithtwodistal
cuffs
Bivonafoamcuff
aluminumspiraltubewithoutersilicone
Coatandselfinflatingfoamspongefilled
cuff

55. 55
AIRWAY CONTROL
Management directly affected in airway surgery
Sharing of airway
UsemicrolaryngealETT,ventilating
bronchoscope,jetventilation,
intermittentintubation
Irregular respiratory movement
use muscle relaxant
Post op laryngeal edema
Use adrenaline, steroids, head up
position, remove stimulus

56. 56
AIRWAY FIRE (0.1%) PROTOCOL
Fatal due to
Thermalinjury,Chemicalburn–
brochospam&edema,melting&burning
ETTleadtoobstruction
Management
-useofspecialtubes
-stopO2,removeETT,floodwithsaline
-bag&mask/venturiventilation
-ifdifficultairway,removeETTonguidewire
-checkbronchoscopy
-postoperative:sittingposition,X-raychest,
antibiotics,humidifiedO
2,steroids

57. 57
THANK YOU