Laryngectomy and major airway resection

Surgical approach

• Total laryngectomy (usually for laryngeal cancer)
  • Neck incision; mobilisation and removal of larynx (± partial pharyngectomy)
  • Creation of a permanent tracheostoma (trachea brought out to skin); airway is permanently separated from upper airway
  • Pharyngeal closure and reconstruction (primary closure or flap); may include neck dissection
  • ± Tracheo-oesophageal puncture (TEP) and voice prosthesis placement (primary or delayed)
• Major airway resection (tracheal or carinal resection; occasionally laryngotracheal)
  • Cervical tracheal resection: collar incision (± partial sternotomy) with segmental tracheal excision and end-to-end anastomosis
  • Thoracic tracheal/carina: right thoracotomy or sternotomy; complex reconstruction
  • Anastomosis protection: neck flexion (chin-to-chest) with sutures; avoid tension
  • Surgeon may request periods of apnoea, cross-field ventilation, jet ventilation, or ECMO depending on lesion and access

Anaesthetic management (headline)

• Type of anaesthesia
  • General anaesthesia with controlled ventilation is usual; consider TIVA when laser/airway fire risk or to facilitate shared airway
  • Regional techniques are adjuncts only (e.g., superficial cervical plexus block rarely; local infiltration by surgeon)
• Airway device / ventilation strategy
  • Laryngectomy: oral ETT initially (often reinforced) then conversion to tracheostomy tube through new stoma; final airway is via stoma only
  • Airway resection: plan depends on level of stenosis/tumour; options include awake fibreoptic intubation, rigid bronchoscopy, small ETT beyond lesion, cross-field sterile ETT, HFJV, or ECMO
• Duration
  • Total laryngectomy: typically 4–8 hours (longer with flap reconstruction/neck dissection)
  • Tracheal resection: typically 3–6 hours; carinal resection often longer and more physiologically stressful
• Pain
  • Moderate–severe: neck incision, tracheostoma discomfort; severe if thoracotomy/sternotomy for carinal work
  • Analgesia: multimodal; consider remifentanil intra-op, morphine/oxycodone post-op; regional options for thoracotomy (paravertebral/erector spinae) if appropriate
• Key intra-op themes
  • Shared airway; frequent circuit disconnections; aspiration/blood contamination risk
  • Need for excellent communication with surgeon and clear triggers for stopping surgery/ventilation changes

Indications and patient factors

• Total laryngectomy: advanced laryngeal malignancy, salvage after radiotherapy/chemoradiotherapy, non-functional larynx/aspiration
• Tracheal resection: post-intubation/tracheostomy stenosis, primary tracheal tumours, invasion from thyroid/oesophagus, trauma, tracheomalacia (selected)
• Common comorbidities: smoking/COPD, alcohol-related disease, malnutrition, anaemia, coronary disease; prior radiotherapy → difficult tissues, poor healing, difficult airway

Pre-operative assessment and optimisation

• Airway assessment is central: symptoms of obstruction (stridor, dyspnoea at rest, positional symptoms), voice change, haemoptysis; review endoscopy/CT and ENT plan
• Identify 'can’t intubate/can’t ventilate' risk: fixed upper airway obstruction, critical tracheal stenosis, friable tumour bleeding; plan for awake technique or rigid bronchoscopy/ECMO standby
• Aspiration risk: dysphagia, pooling secretions, reflux; consider RSI modifications but balance against loss of spontaneous ventilation in obstruction
• Investigations: FBC (anaemia), U&E, coagulation; group & save/crossmatch; ECG; consider ABG/spirometry if COPD; nutritional markers; consider echo if indicated
• Consent/communication: discuss possibility of post-op ventilation, ICU, tracheostomy/stoma, voice loss (laryngectomy), and potential emergency airway strategies
• Premedication: avoid heavy sedation in obstructed airway; antisialagogue (glycopyrrolate) may help for awake fibreoptic; consider PONV prophylaxis

Airway strategy: total laryngectomy

• Induction/intubation: often standard IV induction with oral ETT if airway patent; consider awake fibreoptic if tumour obstructing glottis/supraglottis or limited mouth opening/previous radiotherapy
• Tube choice: reinforced oral ETT often preferred (shared airway, neck manipulation); secure well; throat pack may be used (ensure removal documented)
• Conversion to stoma: when trachea opened and matured, oral ETT is withdrawn and replaced with tracheostomy tube through stoma (often cuffed, non-fenestrated); confirm ETCO2 and bilateral ventilation
• Fire risk: diathermy/laser near oxygen-rich field; keep FiO2 as low as feasible, avoid N2O, good communication before airway entry/diathermy
• Post-laryngectomy anatomy: upper airway no longer communicates with lungs; oxygenation/ventilation must be via stoma only

Airway strategy: major tracheal/carina resection

• Principle: maintain oxygenation/ventilation while allowing surgical access; anticipate switching techniques during case
• Pre-induction planning: agree primary plan + rescue plan with surgeon; have rigid bronchoscope available; prepare difficult airway trolley; consider ECMO standby for critical stenosis/carina involvement
• Induction approach depends on obstruction severity
  • Critical fixed obstruction: avoid paralysis and loss of tone; consider awake fibreoptic to place small ETT beyond lesion, or inhalational induction maintaining spontaneous ventilation, or rigid bronchoscopy under GA with spontaneous ventilation
  • Non-critical lesion: IV induction with paralysis may be acceptable; ensure ability to ventilate before neuromuscular blockade if uncertainty
• Ventilation options during resection/anastomosis
  • Distal (cross-field) ventilation: sterile ETT placed into distal trachea/bronchus by surgeon connected to sterile circuit; common for open tracheal resection
  • High-frequency jet ventilation (HFJV): via catheter/rigid bronchoscope; provides surgical access but risks barotrauma, hypercapnia, inadequate exhalation (esp. distal obstruction)
  • Apnoeic oxygenation: short periods during anastomosis; requires preoxygenation and close timing; CO2 rises rapidly
  • One-lung ventilation: may be required for carinal surgery (DLT/bronchial blocker) but often incompatible with surgical field; cross-field into one main bronchus may be used
  • ECMO (VV or VA): for near-occlusive lesions, carinal reconstruction, severe respiratory failure, or when ventilation impossible/unsafe; requires anticoagulation strategy and specialist team
• Monitoring ventilation: ETCO2 may be unreliable with jet/cross-field; use frequent ABGs, transcutaneous CO2 if available; watch airway pressures and chest movement

Intra-operative management (both procedures)

• Monitoring: standard + arterial line (beat-to-beat, ABGs); consider large-bore IV access; consider central access if major resection/ECMO/poor access; temperature monitoring
• Position: neck extension initially for exposure; later neck flexion to protect tracheal anastomosis (tracheal resection) — ensure ETT not kinked/displaced
• Anaesthetic technique: volatile or TIVA; remifentanil useful for controlled hypotension and smooth emergence; avoid coughing/bucking particularly after airway anastomosis
• Fluids/blood: anticipate moderate blood loss (neck dissection) and potentially major loss (carinal/thoracic); crossmatch; cell salvage may be considered (oncology policy dependent)
• Antibiotics and steroids: per local protocol; consider dexamethasone for airway oedema/PONV (balance glycaemic effects)
• Nerve/structure risks relevant to anaesthesia: recurrent laryngeal nerve (pre-op palsy), vagal stimulation → bradycardia, carotid sinus stimulation; major vessels in field
• Airway fire prevention: minimise FiO2, avoid N2O, allow time for oxygen washout before diathermy in airway, saline available; clear plan if fire occurs (stop gases, remove burning material, flood with saline, re-establish airway)

Extubation and post-operative care

• Total laryngectomy: patient usually emerges breathing via tracheostoma with cuffed tracheostomy tube initially; humidified oxygen, suction, and stoma care are essential
• Tracheal resection: extubation is often preferred early to reduce pressure on anastomosis, but only if safe (good gas exchange, minimal oedema/bleeding, stable repair); otherwise planned ICU ventilation with clear re-intubation plan
• Re-intubation risk: potentially catastrophic for fresh anastomosis; if needed, use experienced operator, fibreoptic guidance, small tube, avoid trauma; involve surgeon early
• Neck flexion sutures after tracheal resection: maintain as prescribed; avoid extension; ensure nursing/ICU aware
• Analgesia: multimodal (paracetamol, NSAID if appropriate, opioids); consider regional for thoracotomy; avoid excessive sedation in airway-compromised patients
• PONV: aggressive prophylaxis to avoid retching/coughing (anastomotic stress, bleeding)
• ICU/HDU: common for major airway resection, flap reconstruction, significant comorbidity, or airway concerns; ensure clear handover including airway anatomy (stoma-only) and emergency plan

Complications (procedure-specific)

• Total laryngectomy
  • Early: bleeding/haematoma, airway obstruction of stoma (crusts, clots), tube displacement, aspiration of blood, flap compromise, hypocalcaemia if thyroid/parathyroid affected (less common than thyroidectomy but possible with extensive surgery)
  • Pharyngocutaneous fistula (risk ↑ with prior radiotherapy, malnutrition); sepsis; wound breakdown
  • Long-term: stomal stenosis, tracheo-oesophageal prosthesis issues, pulmonary infections due to loss of upper airway humidification
• Tracheal/carina resection
  • Anastomotic dehiscence (life-threatening), restenosis/granulation, recurrent laryngeal nerve injury/hoarseness, infection/mediastinitis
  • Respiratory: pneumothorax, barotrauma (jet ventilation), atelectasis, pneumonia; hypercapnia during HFJV/apnoea
  • Cardiovascular: major haemorrhage, arrhythmias (carinal manipulation), air embolism (rare)

Emergency considerations (ward/ED/ICU)

• Post-laryngectomy patient in respiratory distress: oxygenate/ventilate via stoma only (face mask to mouth/nose is ineffective); apply paediatric mask or tracheostomy mask to stoma; suction; consider replacing tube
• If stoma obstruction: remove inner cannula (if present), suction, humidify, consider saline nebulisers; if cannot ventilate, attempt stoma intubation with small cuffed ETT over bougie/fibreoptic; call ENT
• After tracheal resection: any stridor, subcutaneous emphysema, sudden respiratory compromise, or haemoptysis → suspect anastomotic problem; urgent senior review and bronchoscopy may be required