Laryngectomy Overview: Understanding Cancer Risks
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Questions and Answers

What is the most common form of laryngeal malignancy?

  • Pharyngeal cancer
  • Supraglottic cancer
  • Subglottic cancer
  • Glottic cancer (correct)

    • Which factors primarily contribute to the majority of laryngeal neoplasms?

  • Tobacco use and alcohol misuse (correct)
  • Occupational exposure and viral infections
  • Environmental pollutants and smoking
  • Genetic predisposition and diet

    • Which cancer staging system is used to dictate the treatment and surgical approach for laryngeal cancer?

  • BCLC (Barcelona Clinic Liver Cancer)
  • FIGO (International Federation of Gynecology and Obstetrics)
  • TNM (tumor, node, metastasis) (correct)
  • AJCC (American Joint Committee on Cancer)

    • What is a primary concern for the anesthetist during the intraoperative period in laryngectomy?

    <p>Airway protection and massive hemorrhage (B)</p> Signup and view all the answers

    What plays a crucial role in deciding whether a patient can be intubated safely during laryngectomy?

    <p>Thorough diagnostic information and airway assessment (A)</p> Signup and view all the answers

    Which of the following cartilages is NOT paired within the larynx?

    <p>Thyroid (D)</p> Signup and view all the answers

    What is the primary nerve responsible for motor innervation to the cricothyroid muscle?

    <p>External branch of the superior laryngeal nerve (B)</p> Signup and view all the answers

    What is the functional significance of the intrinsic muscles of the larynx?

    <p>Regulating the tension of the vocal cords (A)</p> Signup and view all the answers

    If a surgical procedure compromises the internal branch of the superior laryngeal nerve, what would be the primary consequence?

    <p>Loss of sensation above the vocal cords (D)</p> Signup and view all the answers

    Which anatomical landmark is MOST critical for the anesthesiologist performing cricothyroidotomy?

    <p>Cricothyroid membrane (D)</p> Signup and view all the answers

    Based on the provided information, what is the approximate ratio of men to women diagnosed with laryngeal cancer?

    <p>10:1 (C)</p> Signup and view all the answers

    If tobacco use and alcohol consumption are BOTH present, what is the approximate multiplicative effect on the incidence of laryngeal cancer?

    <p>15.5 times (A)</p> Signup and view all the answers

    Which of the following tumor locations accounts for the largest proportion of all laryngeal neoplasms?

    <p>Glottic (C)</p> Signup and view all the answers

    Which statement BEST reflects the relationship between risk factors and incidence of laryngeal cancer?

    <p>The presence of risk factors significantly increases the likelihood of developing laryngeal cancer. (B)</p> Signup and view all the answers

    Based solely on the information provided, which statement is TRUE about the incidence of laryngeal cancer?

    <p>The incidence of laryngeal cancer is relatively consistent at approximately 3.7 per 100,000 people. (B)</p> Signup and view all the answers

    Which type of laryngectomy preserves the cricoid cartilage, but carries the risk of continued dependence on a tracheotomy?

    <p>Supracricoid laryngectomy (D)</p> Signup and view all the answers

    A patient with extensive cancerous involvement of the larynx, classified as T3 or T4, would most likely undergo which type of laryngectomy?

    <p>Total laryngectomy (A)</p> Signup and view all the answers

    Which laryngectomy procedure is performed for early-stage laryngeal cancers and aims to preserve laryngeal function while removing diseased tissue?

    <p>Microlaryngeal surgery (B)</p> Signup and view all the answers

    Which type of laryngectomy involves the removal of one half of the larynx, and may involve reconstruction of the vocal cord using the strap muscle?

    <p>Hemilaryngectomy (A)</p> Signup and view all the answers

    Which laryngectomy procedure is suitable for lesions near the anterior glottis and may potentially preserve vocal function, although a significant portion of patients require a tracheotomy?

    <p>Supracricoid laryngectomy (A)</p> Signup and view all the answers

    Which of the following symptoms is NOT commonly associated with laryngeal carcinoma?

    <p>Muffled speech (A)</p> Signup and view all the answers

    Which diagnostic tool is primarily used to confirm the presence of laryngeal carcinoma?

    <p>Laryngoscopy with biopsy (D)</p> Signup and view all the answers

    Which stage classification would be appropriate for a laryngeal carcinoma identified as T2, N0, M0?

    <p>Stage II (C)</p> Signup and view all the answers

    Which of the following conditions is most likely linked with increased risk for laryngeal carcinoma?

    <p>Cigarette smoking (D)</p> Signup and view all the answers

    What is a common management strategy for a patient with COPD undergoing laryngectomy?

    <p>Anticholinergic inhalers (B)</p> Signup and view all the answers

    Why is a semi-Fowler or side-lying position sometimes preferred for laryngectomy patients?

    <p>To alleviate airway obstruction and improve functional residual capacity. (D)</p> Signup and view all the answers

    What is the primary reason for pre-oxygenating laryngectomy patients before intubation?

    <p>To minimize the risk of hypoxia during the intubation process. (B)</p> Signup and view all the answers

    Which specific aspect of the surgical setup is primarily influenced by the anesthetist's limited access to the patient's airway?

    <p>The positioning of the operating table. (B)</p> Signup and view all the answers

    What is the main rationale for utilizing two large-bore IVs in laryngectomy patients?

    <p>To ensure adequate fluid and drug administration during surgery. (C)</p> Signup and view all the answers

    Why is the femoral vein preferred for central line placement in laryngectomy patients?

    <p>It minimizes the risk of interfering with the surgical field. (A)</p> Signup and view all the answers

    Which of the following regional anesthetic techniques targets the nerve responsible for sensation of the vocal cords?

    <p>Superior laryngeal nerve block (A)</p> Signup and view all the answers

    Flashcards

    Laryngeal Cancer Causes

    Squamous cell carcinoma is the main cause of laryngeal cancer, linked to tobacco and alcohol use.

    Forms of Laryngeal Cancer

    Glottic cancer is most common, followed by supraglottic and subglottic types.

    TNM Staging

    TNM stands for tumor, node, metastasis; it guides cancer treatment and surgery.

    Airway Management in Laryngectomy

    Diagnosis and airway assessment are crucial for intubation and airway techniques.

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    Intraoperative Concerns

    The anesthetist prioritizes airway protection and managing massive hemorrhage during surgery.

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    Laryngeal Cartilages

    The larynx has three unpaired (epiglottis, thyroid, cricoid) and three paired cartilages (arytenoid, corniculate, cuneiform).

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    Laryngeal Regions

    The larynx is divided into three regions: supraglottic, glottic, and subglottic.

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    Laryngeal Muscles

    Extrinsic muscles move the larynx, while intrinsic muscles adjust vocal cord tension for sound production.

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    Nerve Supply of Larynx

    Recurrent laryngeal nerve innervates below vocal cords; superior laryngeal nerve innervates above vocal cords.

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    Cricothyroid Membrane

    The cricothyroid membrane is a crucial landmark for procedures like cricothyroidotomy.

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    Laryngeal Cancer Statistics

    Laryngeal cancer primarily affects men aged 50-70, accounting for 1% of all cancers.

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    Common Causes of Laryngeal Cancer

    95% of laryngeal cancers are linked to tobacco and alcohol use.

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    Glottic Tumors

    Glottic tumors are the most common type of laryngeal cancer, making up 60% of cases.

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    TNM Staging Breakdown

    TNM stands for tumor size (T), lymph node involvement (N), and metastasis (M).

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    Impact of Risk Factors

    Combining tobacco and alcohol increases laryngeal cancer risk by 15.5 times.

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    Microlaryngeal Surgery

    A surgical technique for early-stage laryngeal cancers using a microscope and laser to remove diseased tissue.

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    Hemilaryngectomy

    Surgery that removes one vertical half of the larynx, allowing for potential vocal cord reconstruction.

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    Supracricoid Laryngectomy

    Surgery involving the removal of supraglottic structures and vocal cords while preserving cricoid and arytenoid cartilages.

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    Total Laryngectomy

    Complete removal of the larynx and surrounding structures due to extensive cancer involvement.

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    Postoperative Factors

    The recovery process depends on the cancer's extent, the type of laryngectomy, and the patient's health.

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    Signs of Laryngeal Carcinoma

    Common signs include hoarseness, painful swallowing, persistent cough, and dyspnea.

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    Comorbidities in Laryngectomy

    Hypertension and COPD are common comorbidities often linked to laryngectomy patients.

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    Diagnostic Testing for Laryngeal Carcinoma

    Laryngoscopy and biopsy are definitive tests, alongside CT and PET scans for staging.

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    Stage II Laryngeal Cancer

    Identified as T2, NO, MO; it shows localized disease without lymph node involvement.

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    Role of CXR in Laryngeal Cancer

    Chest X-Ray (CXR) is not used for laryngeal malignancy but can identify lung metastasis.

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    Patient Positioning for Laryngectomy

    Patients are usually placed supine, but may need semi-Fowler or side-lying if airway obstruction is present.

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    Preoxygenation Importance

    Thorough preoxygenation is crucial before intubation to prevent hypoxia during surgery.

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    Risk of Airway Bleeding

    Trauma during laryngoscopy can lead to bleeding, especially in irradiated tissues.

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    Use of Video Laryngoscopy

    Video laryngoscopy may aid in intubation when there's risk of bleeding from post-radiation changes.

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    Endotracheal Tube (ETT) Considerations

    Multiple ETT sizes should be available for potential intubation difficulties; secure as discussed with the surgeon.

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    Deep cervical plexus block

    Local anesthesia is injected into the bilateral transverse processes of C4.

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    Signs of Laryngeal Cancer

    Symptoms include hoarseness, painful swallowing, cough, and airway obstruction.

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    Vocalis muscle

    An intrinsic muscle of the larynx that adjusts tension of the vocal cords.

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    Superficial cervical plexus block

    Local anesthesia is injected around the Erb point on both sides of the neck.

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    Study Notes

    Laryngectomy Overview

    • Laryngeal cancer, predominantly squamous cell carcinoma, is a significant concern, affecting men aged 50-70 more frequently.
    • It accounts for 1% of all malignancies and is the 11th most prevalent cancer in men, with men being 10 times more likely to develop it than women.
    • The overall incidence of laryngeal neoplasm is 3.7 per 100,000.
    • Squamous cell cancer accounts for 95% of all laryngeal carcinoma.
    • Tobacco use and alcohol consumption are the leading causes of laryngeal malignancy, contributing to 95% of cases.
    • Combining these risks increases laryngeal cancer incidence by 15.5 times.
    • Glottic tumors are the most common, representing 60% of laryngeal neoplasms.
    • Supraglottic cancers comprise 35% of cases, and subglottic cancers account for 5%.
    • Cancer staging (TNM system) significantly influences surgical and treatment choices.
    • Classic signs include hoarseness (glottic involvement), difficult or painful swallowing (dysphagia/odynophagia), persistent coughing, and dyspnea. Many signs appear late, especially with supraglottic and subglottic cancers (80% of subglottic tumors diagnosed in late stages, T3 or T4). Additional signs include muffled voice, otalgia (earache), cough, airway obstruction, fixation of the thyroid cartilage, neck mass, stridor, hemoptysis (coughing up blood), anorexia, and weight loss.
    • Diagnostic testing and airway evaluations are vital to assuring patient safety concerning intubation and definitive airway management.
    • Protecting the airway and managing potential massive hemorrhage are critical concerns for the anesthetist.
    • The larynx protects and supports the airway, composed of three unpaired cartilages (epiglottis, thyroid, cricoid) and three paired cartilages (two arytenoid, two corniculate, and two cuneiforms).
    • The anatomy is divided into supraglottic, glottic, and subglottic regions.
    • The supraglottic region includes the epiglottis, arytenoids, and false vocal cords; the glottic region comprises the true vocal cords and the glottic opening; and the subglottic area extends from beneath the glottic opening to the cricoid cartilage.
    • The cartilages are connected by the thyrohyoid, cricotracheal, cricothyroid, and hypoepiglottic ligaments.
    • The cricothyroid membrane is a key landmark for cricothyroidotomy.
    • Laryngeal muscles are categorized into extrinsic and intrinsic groups.
    • Extrinsic muscles move the larynx; intrinsic muscles control vocal cord tension for phonation.
    • The extrinsic muscles include the sternothyroid and thyrohyoid, and inferior constrictor of the pharynx.
    • Intrinsic muscles include the posterior cricoarytenoid, lateral cricoarytenoid, interarytenoid, thyroarytenoid, vocalis, and cricothyroid.
    • The recurrent laryngeal nerve and superior laryngeal nerve innervate the larynx.
    • The recurrent laryngeal nerve primarily provides sensory innervation below the vocal cords, with the internal branch of the superior laryngeal nerve sensing those above.
    • The recurrent laryngeal nerve supplies most motor innervation, excluding the cricothyroid muscle, which the external branch of the superior laryngeal nerve innervates.
    • Both nerves are branches of the vagus nerve.
    • The superior laryngeal artery (from the external carotid) and inferior laryngeal artery (from the subclavian) supply blood.
    • The superior and inferior laryngeal veins manage venous drainage.
    • TNM staging defines tumor size (T), lymph node involvement (N), and metastasis (M).

    Surgical Procedures

    • Laryngeal surgery aims to remove diseased tissue, establish or maintain airways, and preserve vocal cord function.
    • Surgical techniques vary based on tumor invasion:
      • Microlaryngeal surgery: Used for early-stage cancers; preserves adjacent structures and postoperative laryngeal function.
      • Hemilaryngectomy: Removes one half of the larynx, with vocal cord reconstruction possible using strap muscles.
      • Supracricoid laryngectomy: Removes supraglottic structures (true and false vocal cords, thyroid cartilage); cricoid and arytenoids remain. May preserve vocal function, but up to 50% of patients require a tracheostomy.
      • Supraglottic laryngectomy: Removes supraglottic structures (false vocal cords, epiglottis, arytenoids, some cartilage) via endoscopic or open techniques.
      • Total laryngectomy: Removes the entire larynx (including thyroid, cricoid cartilages, hyoid bone, and potentially tracheal rings). May involve partial thyroid resection. Creates a permanent tracheostomy.

    Postoperative Course and Complications

    • Postoperative recovery depends on tumor extent, laryngectomy type, and patient condition.
    • Potential complications include:
      • Speech difficulties
      • Airway complications
      • Diminished taste and smell
      • Pharyngoesophageal stenosis
      • Tracheoesophageal fistula
      • Infections
      • Scarring reducing range of motion
      • Hematoma formation
      • Cranial nerve damage
    • Operative times vary, with radical neck dissections adding extended durations (exceeding 10 hours when combined).
    • Blood loss is usually less than 300-400 mL, reducing the need for transfusions.

    Anesthetic Management and Considerations

    • Preoperative Period:

      • Signs and symptoms: Hoarseness, difficult or painful swallowing, persistent coughing, dyspnea, muffled voice, otalgia, cough, airway obstruction, neck mass stridor, hemoptysis, anorexia, and weight loss are common.
        • Comorbidities: COPD (emphysema, chronic bronchitis, asthma), cerebrovascular accident, lung cancer, intermittent claudication, coronary artery disease, myocardial infarction, atherosclerosis, hypertension, alcohol abuse, hepatic failure, renal failure, and tobacco use are common. Management includes ipratropium & albuterol inhalers (COPD), metoprolol & amlodipine (HTN).
        • Preoperative Diagnostic testing: Laryngoscopy, biopsy, CT scan (tumor size, lymph node), PET scan (metastasis). Chest X-ray (lung metastasis, not for laryngeal cancer).
        • Preoperative Laboratory Evaluation: CBC, Type and Screen (T&S), LFTs, PT/PTT, electrolyte panel, ABG. Conditions like polycythemia (from COPD) and potential cardiac issues (from hypertension).
        • Airway Assessment: Critical; assess Mallampati class, thyromental distance, and ability to lie supine. Awake intubation or tracheostomy (with or without sedation) might be necessary. A supraglottic device (LMA) may be inappropriate.

    • Intraoperative Period

      • Patient Position: Supine (unless preexisting airway obstruction); semi-Fowler or side-lying may be necessary, discuss head position.
      • Airway Management: Trauma during laryngoscopy and intubation can lead to swelling and bleeding; radiation therapy can increase risk. Video laryngoscopy may be helpful. Direct laryngoscopy, multiple ETT sizes, and secure taped/sutured ETT placement are essential.
      • Patient Access: Two large-bore IVs for access; potential for central line (femoral vein).
      • Protecting Eyes: Careful eye protection and covering are essential.

    • Intraoperative Monitoring: Standard monitors (ECG, NIBP, pulse oximetry, EtCO2, peripheral nerve stimulator, temperature) are crucial. Arterial line placement recommended. Blood loss (200-500 mL) and hypotension (hemorrhage or vagal stimulation) concerns. Esophageal stethoscope for core temperature and auscultation essential.

    • Patient Warming: Patient warming (lower body or underbody Bair Hugger) and heated intravenous fluids recommended.

    • Regional Anesthetic Techniques:

      • Deep cervical plexus block: local anesthesia in C4 transverse processes.
      • Superficial cervical plexus block: infiltration around Erb point.
      • Superior laryngeal nerve: bilateral injection 1 cm below hyoid greater cornu.
      • Translaryngeal block: injection through cricothyroid membrane.

    • Intraoperative Complications: Hemorrhage and vagal nerve stimulation leading to hypotension/bradycardia are possible. Pulmonary and airway complications (pneumothorax, airway obstruction, air embolism) require prompt attention. Careful extubation evaluation is essential.

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    Description

    This quiz delves into the critical aspects of laryngectomy, including the types of laryngeal cancer, risk factors, and the importance of diagnostic testing. You'll explore how cancer staging affects treatment choices and the anesthetist's role in managing airway safety during surgery. Enhance your knowledge of laryngeal health and surgical considerations.

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