**3.5 In case of difficult exposure of the larynx**

	- A. Limited neck extension
	- B. Big tongue/difficult palatal visualization
	- C. Retrognathia

#### **3.6 Alternative techniques to get an airway in case of "difficult exposure"**


#### **4. Airway management techniques in head and neck cancer surgeries**

#### **4.1 Synopsis**

Airway management for surgery of head and neck cancer (HNC) patients is a challenge for the otolaryngologist and anesthesiologist. Appropriate assessment and planning are mandatory for successful airway management. In this chapter, we will review the most common head and neck cancer imposing difficult airway and discuss the strategies of airway management in these patients undergoing head and neck cancer surgery.

#### **4.2 Introduction**

Head and neck tumors and malignancies are prominent and relatively frequent. Squamous cell carcinoma represents 90% of head and neck malignancies. (11).

Airway management for head and neck tumors surgery demands special consideration and high focus.

The difficulties and challenges in the airway management of surgical patients with head and neck malignancies are primarily secondary to distortion of normal anatomy (like mass effect) and alteration of the normal physiology (like trismus) of upper airways. In addition, any previous surgery or radiotherapy (neck stiffness and inadequate neck extension) add more difficulty to airway management in these patients. Also, head and neck malignancies resection surgeries are long and extensive procedures which usually lead to significant postoperative swelling and thus the risk of secondary iatrogenic upper airway compromise.

Detailed knowledge of tumor type and localization, size, and vascularity is essential for definitive planning of proper airway management and to avoid any complications during intubation or ventilation [8].

#### **4.3 Recognition of the difficult airway**

It is essential to identify any possible airway difficulty management preoperatively. During history taking, any obstructive symptoms should be noted.

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*Airway Management in Head and Neck Pathology DOI: http://dx.doi.org/10.5772/intechopen.94498*

carcinomas.

intubation.

necrotic.

hoarseness.

**Large goiters**

tive flexible laryngoscopy.

**Symptoms suggestive of airway obstruction:**

• **Dysphagia**: suggestive of a pharyngeal problem

predictive of a relatively straight axis to the glottis.

wake intubation is the most appropriate course.

• *A wake fiberoptic intubation* is the gold standard.

• *A wake oral laryngoscopy* is an acceptable alternative.

**Hypopharyngeal tumors:**

**There are other essential points to be checked as well:**

tumors and its extension and encroachment on the airway [9].

**4.4 Common airway pathology that indicates difficult airway**

• **Hoarseness:** an early symptom of glottic carcinoma; late with supra-glottic

• **Stridor**: biphasic one is suggestive of glottic narrowing, inspiratory one of a

subglottic narrowing, and expiratory of a supra-glottic narrowing.

**Mouth opening:** of at least 3 cm is necessary for successful laryngoscopy. **Mallampati** classification can provide valuable and essential information about the size of the tongue in relation to the oral cavity and is a useful predictor of ease of

**Size of the mandibular space:** 2 fingerbreadths or more suggest easy intubation. **Can the patient assume the sniffing position?** Ability to assume this position is

**Endoscopic examination:** to localize any narrowing and assess its significance. **CT scanning with 3D reconstruction and virtual bronchoscopy:** is especially valuable in evaluating the size and extent of lesions. Three-dimensional reconstruction with virtual endoscopy improves the ability to more fully assess head and neck

The hypopharynx extends from the level of hyoid bone superiorly to the level of cricoid cartilage inferiorly and consists of three parts: pyriform sinus, postcricoid area, and posterior pharyngeal wall. Tumors arising in the hypopharynx are most often localizing in the piriform sinus. Hypopharyngeal cancers are usually silent and grow to a significant size to cause symptoms; the central core can be

**Presentation**: it is usually very late. Progressive dysphagia and late onset

• Blind intubation techniques are relatively contraindicated because of the possibility of tumor disruption and significant bleeding (**Figure 9**).

Thyroid cancers or large goiters can be threatening to the upper airway by external airway compression, deviation, distortion, or even local invasion of the trachea. Long term compression may lead to softening of the trachea (tracheomalacia). Involvement of the recurrent laryngeal nerve may jeopardize an already compromised airway by causing additional narrowing of the glottis. The status of the recurrent laryngeal nerve and glottis opening can be assessed by a routine preopera-

**Airway Management:** given the potential for airway obstruction with apnea, a

*Special Considerations in Human Airway Management*

E. Trismus/reduced inter-incisor opening

B. Tracheostomy done with local anesthesia.

E. Ossoff–Pilling laryngoscope.

**4.1 Synopsis**

neck cancer surgery.

eration and high focus.

**4.2 Introduction**

F. Laryngeal Mask Airway (LMA).

**3.6 Alternative techniques to get an airway in case of "difficult exposure"**

A. Awake, flexible laryngoscopy with naso-tracheal intubation.

C. Intubation by using specialized "anterior" laryngoscope.

D. Use of a curved ETT with stylet and Sliding Jackson laryngoscope.

G. Use of laryngoscopy and intubation without seeing of vocal cords.

**4. Airway management techniques in head and neck cancer surgeries**

Airway management for surgery of head and neck cancer (HNC) patients is a challenge for the otolaryngologist and anesthesiologist. Appropriate assessment and planning are mandatory for successful airway management. In this chapter, we will review the most common head and neck cancer imposing difficult airway and discuss the strategies of airway management in these patients undergoing head and

Head and neck tumors and malignancies are prominent and relatively frequent.

Airway management for head and neck tumors surgery demands special consid-

The difficulties and challenges in the airway management of surgical patients with head and neck malignancies are primarily secondary to distortion of normal anatomy (like mass effect) and alteration of the normal physiology (like trismus) of upper airways. In addition, any previous surgery or radiotherapy (neck stiffness and inadequate neck extension) add more difficulty to airway management in these patients. Also, head and neck malignancies resection surgeries are long and extensive procedures which usually lead to significant postoperative swelling and thus

Detailed knowledge of tumor type and localization, size, and vascularity is essential for definitive planning of proper airway management and to avoid any

It is essential to identify any possible airway difficulty management preopera-

tively. During history taking, any obstructive symptoms should be noted.

Squamous cell carcinoma represents 90% of head and neck malignancies. (11).

the risk of secondary iatrogenic upper airway compromise.

complications during intubation or ventilation [8].

**4.3 Recognition of the difficult airway**

D. Short, thick neck

**136**
