Case Report
Aspiration Prevention Surgery under Local Anesthesia for Palliative Care in Patients with Head and Neck Cancer: A Report of Two Cases
Misaki Sekiguchi Koyama
aRumi Ueha
aTakao Goto
aTaku Sato
aAkane Tachibana
aYui Mizumoto
aTakaharu Nito
bTatsuya Yamasoba
aaDepartment of Otolaryngology and Head and Neck Surgery, University of Tokyo, Tokyo, Japan; bDepartment of Otolaryngology, Saitama Medical Center, Saitama, Japan
Keywords
Head and neck neoplasms · Local anesthesia · Palliative care · General surgery · Swallowing disorders
Abstract
Aspiration prevention (AP) surgery may improve the quality of life (QOL) of patients with se- vere dysphagia. However, not all patients can endure this type of surgery under general an- esthesia because of their poor status. Herein, we describe the cases of 2 patients with head and neck cancer (HNC) who underwent AP surgery for palliative care. Although both patients had tracheostomy due to severe dysphagia and respiratory impairment and frequently need- ed suction, they were successfully managed with AP surgery under local anesthesia. A trache- ostoma was reshaped to be sufficiently large for an airway to be secured without a cannula.
Their respiratory failure gradually improved, and suction frequency markedly decreased after surgery; thus, they could receive medical treatment at home. When patients with HNC under palliative care have a tracheal cannula and cannot vocalize, AP surgery under local anesthesia is an option to improve their QOL.
© 2020 S. Karger AG, BaselIntroduction
Patients with head and neck cancer (HNC) can have various physical symptoms, such as pain, dysphagia, and a speech impediment [1]. The quality of life (QOL) of patients with severe dysphagia and/or tracheotomy is often extremely low because they often cannot orally ingest food and need frequent sputum suction [2]. Taken together, palliative care for terminal
Rumi Ueha
Department of Otolaryngology and Head and Neck Surgery University of Tokyo
7-3-1 Hongo Bunkyo-ku, Tokyo 113-8655 (Japan) UEHAR-OTO@h.u-tokyo.ac.jp
to this disease or its treatment [1].
Aspiration prevention (AP) surgery has been found to be useful for improving the QOL of patients with dysphagia [2]. Total laryngectomy or laryngotracheal separation under general anesthesia is commonly attempted to reduce the frequency of secretion suction and the inci- dence of aspiration pneumonia and to reestablish oral intake [3]. However, not all patients can endure such surgery under general anesthesia because of their poor status. It is important, therefore, to explore the potential of AP surgery under local anesthesia to improve the QOL of such patients.
Herein, we report the cases of 2 patients with HNC who underwent AP surgery under local anesthesia for palliative care with the aim of improving their QOL.
AP Surgery under Local Anesthesia
Local anesthesia is of the outmost importance during surgery due to its analgesic and antitussive effects. Preliminarily, a sheet of surgical gauze soaked in 4–8% lidocaine is placed on the neck to reduce painful sensations on the skin, followed by subcutaneous adminis- tration of 0.5–1.0% lidocaine. Next, bilateral superior laryngeal nerve block with 0.5–1.0%
lidocaine is conducted to reduce the laryngeal sensation. Whenever the patient feels pain, an additional 0.5–1.0% lidocaine (2–5 mL/time) is topically injected into the surrounding tissue and muscles. The total amount of lidocaine should be within 20 mg/50 kg. During surgery, it is important to monitor the patient’s vital signs and administer oxygen as needed. Pharyngeal secretions entering the surgical field, such as the laryngeal rumen and trachea, should be eliminated. Reassuring the patient during the procedure could also help maintain the vital signs stable.
The surgery starts with the patient at rest. The skin and subcutaneous tissues are incised in the midline. Following strap muscle division, the thyroid and cricoid cartilages are exposed.
After resection of the frontal third of the thyroid and cricoid cartilages, the subglottic area is exposed. We respond by interrupting the procedure when the patient coughs. Once the laryngeal lumen is opened, administration of the local anesthetic mentioned above into the laryngeal mucosa and placement of an anesthetic-impregnated gauze on the tracheal wall are required to suppress the cough reflex. We can select the surgical procedure for AP according to the general and swallowing conditions of the patient as follows: supraglottic laryngeal closure at the upper laryngeal part, glottic laryngeal closure at the glottis level, and subglottic laryngeal closure at the level of the cricoid cartilage. The closed area is reinforced with the sternohyoid muscle and/or part of the thyroid cartilage, and then a permanent tracheostoma is created.
Case Presentation Case 1
A 69-year-old man had been hospitalized in a certain hospital for recurrent aspiration pneumonia, resulting in an impaired physical status and respiratory dysfunction. At the age of 68 years, he underwent partial glossectomy with free flap reconstruction, neck dissection, and tracheotomy for tongue carcinoma (cT3N0M0). Before this surgery, upper gastrointestinal endoscopy revealed the co-presence of hypopha- ryngeal squamous cell carcinoma (cT1N0M0) and esophageal cancer (cT2N0M0). Subsequently, transthora- coabdominal subtotal esophagectomy was performed.
After the surgery, acute respiratory distress syndrome occurred and was exacerbated by bacterial pneu- monia, resulting in the need to use mechanical ventilation. Accordingly, he was transferred to another hospital with a ventilator. Four months after the transfer, the ventilator could be withdrawn, but the tracheal cannula could not be removed because of insufficient respiratory function and excessive sputum with severe dysphagia. He developed aspiration pneumonia numerous times and the C-reactive protein level was high at
all measurement points. Besides, the hypopharyngeal squamous cell carcinoma remained untreated because he refused intensive treatment and selected palliative care. Therefore, AP surgery under local anesthesia was considered to improve his QOL, as surgery under general anesthesia was judged to be beyond indication because of his poor general condition and poor respiratory function.
He was transferred again to our institution for the AP surgery. At that time, we acquired the following laboratory results: white blood cells, 11,700 cells/mm3; neutrophils, 64%; lymphocytes, 17%; hemoglobin, 11.1 g/dL; albumin, 2.5 g/dL; and C-reactive protein, 1.52 mg/dL. Blood gas analysis revealed a pH of 7.46, carbon dioxide partial pressure of 36.1 mm Hg, and oxygen partial pressure of 120.1 mm Hg (2 L oxygen via a nasal cannula). The tracheostoma was almost entirely closed by granulation tissue (Fig. 1a). A videofluoro- scopic swallowing study (VFSS) showed that contrast agent was aspirated into the trachea without recog- nition and that no contrast agent could pass through the upper esophageal sphincter (Fig. 1b). AP surgery for palliative care was performed to prevent aspiration pneumonia recurrence and to reduce the number of suctions.
Operative Findings
AP surgery was performed under local anesthesia, as depicted in Figure 2. Considering the severe systemic condition of the patient and the potential risks, such as of respiratory failure and cardiac arrest during surgery, anesthesiologists attended the AP surgery to manage the condition of the patient. During the operation, the systolic blood pressure (BP) ranged from 120 to 90 mm Hg, the diastolic BP from 50 to 70 mm Hg, and the heart rate from 90 to 120 bpm. As saliva-sputum constantly flowed into the laryngotracheal area and the oxygen saturation of the peripheral artery (SpO2) dropped to 80%, we had to perform frequent intra-
a b
Fig. 1. Preoperative findings.
a Tracheostoma findings. Pres- ence of granulation tissue around the tracheostoma. b View of the videofluoroscopic swallowing study. Contrast agent did not pass through the upper esophageal sphincter (black arrow) and was aspirated into the trachea (white arrowhead).
b c
Fig. 2. Intraoperative findings in case 1. a Line of skin incision. b Subglottic laryngeal closure was performed at the level of the cricoid cartilage, and the closed area was reinforced with a part of the thyroid cartilage (white arrowhead). c Closure of the suture and creation of a permanent tracheostoma.
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tracheal suction and oxygen administration until the surgery was completed. With 1 L of oxygen, we were able to maintain an SpO2 greater than 98%.
Laryngeal closure was performed at the subglottis with cricopharyngeal myotomy on both sides. The closed subglottic area was reinforced with a piece of the thyroid cartilage, and then a permanent trache- ostoma was created.
Postoperative Course
After surgery, the patient’s course was uneventful. The suction frequency decreased and his respiratory condition gradually improved. Surprisingly, oxygen demand was withdrawn on postoperative day 3, and the tracheal cannula could be removed on postoperative day 7. A postoperative blood gas analysis revealed a pH of 7.47, carbon dioxide partial pressure of 32.6 mm Hg, and oxygen partial pressure of 94.3 mm Hg (room air) on postoperative day 3, and C-reactive protein became negative on postoperative day 6. A large permanent tracheostoma was created (Fig. 3a). The postoperative VFSS (Fig. 3b) showed no leakage at the closure site.
Although an amount of contrast agent flowed into the intralaryngeal area, a small amount of contrast agent could pass through the upper esophageal sphincter to the esophagus. The patient could resume oral intake of small amounts of liquid and returned to the previous hospital on postoperative day 14. Three months post- operatively, the patient was adjusting to his general condition with the aim of returning home.
Case 2
A 67-year-old man was emergently admitted to our hospital because of aspiration pneumonia. He had several serious medical conditions and a past medical history including type 2 diabetes, surgery for esoph- ageal carcinoma, surgery and postsurgical chemoradiotherapy for lung small cell carcinoma, and recurrent aspiration pneumonia. At the age of 62 years, he was treated for hypopharyngeal carcinoma (cT1N0M0) with hypopharyngectomy followed by radiotherapy. At the age of 64 years, he underwent partial glossectomy for tongue carcinoma (cT2N0M0), and then a second partial glossectomy with free flap reconstruction, neck dissection, and tracheotomy was performed for tongue cancer recurrence at the age of 65 years. At the age of 67 years, lower gingival carcinoma (cT2N0M0) was discovered, and marginal mandibulotomy and trache- ostomy were performed. Gastrostomy was simultaneously created. His swallowing function progressively worsened after the surgeries.
During hospitalization, oropharyngeal carcinoma at the left side (cT1N2M0) was detected. Considering his past surgical history, poor general condition, and poor respiratory function, surgical resection under general anesthesia was not indicated. Thus, it was decided that the patient would be supported by palliative care. At that time, we acquired the following laboratory results: white blood cells, 10,500 cells/mm3; neutro- phils, 73%; lymphocytes, 23%; hemoglobin, 11.6 g/dL; albumin, 2.7 g/dL; and C-reactive protein, 0.45 mg/
dL. Blood gas analysis revealed a pH of 7.43, carbon dioxide partial pressure of 46.6 mm Hg, and oxygen partial pressure of 60.1 mm Hg (room air). A chest radiograph showed a vanishing tumor in the right lobe and pulmonary congestion in the right apex. A VFSS revealed severe pharyngoesophageal dysphagia and contrast agent aspiration into the trachea, and the contrast agent could not pass through the upper esoph- ageal sphincter. Consequently, as a means of palliative care, AP surgery under local anesthesia was proposed to prevent intractable and recurrent aspiration pneumonia, and the patient agreed to undergo the operation.
b Fig. 3. Postoperative findings.
a Large permanent tracheosto- ma without a tracheal cannula.
b View of the videofluoroscopic swallowing study; contrast agent flowed into the intralaryngeal area, but no leakage was found at the closure site (white arrow- head). A small amount of contrast agent could pass through the up- per esophageal sphincter to the esophagus (black arrow).
Color version available online
Operative Findings
AP surgery was performed using a glottic closure procedure, removing the cricoid cartilage under local anesthesia, as depicted in Figure 4, in the semi-sitting position because the patient had difficulty breathing in the dorsal position. We previously reported that in this manner, cricopharyngeal myotomy by an anterior approach could be executed concurrently in the same operative field [4].
As the patient’s condition was severe, an anesthesiologist was present to support and control the patient’s vitals during the AP surgery. During the operation, the systolic BP ranged from 125 to 90 mm Hg and the diastolic BP ranged from 70 to 80 mm Hg. The patient’s BP temporarily dropped to 80/50 mm Hg, but we were able to control the intraoperative BP using ephedrine. His heart rate was approximately 85 bpm, and the SpO2 was 100% with 1 L of oxygen. Although the operative field was narrow and limited because of the patient’s posture and the procedure was repeatedly interrupted due to the patient’s condition, it was eventually completed. The closed glottis was reinforced with the anterior cervical muscle, and then a permanent tracheostoma was created.
Postoperative Course
The postoperative course was favorable. The tracheal cannula could be removed on postoperative day 15, and the suction frequency of the tracheostoma decreased. His respiratory condition gradually improved.
A postoperative VFSS showed no leakage of the closure site, and a small amount of contrast agent could pass from the pharynx to the esophagus. He could resume oral intake of small amounts of liquid and returned home on postoperative day 28. Thereafter, aspiration pneumonia did not recur, and he died at home 6 months after discharge.
b c d
e f g h
Fig. 4. Intraoperative findings in case 2. a Line of skin incision. b Incision of the skin and subcutaneous tis- sue. c Exposure of the thyroid cartilage (white arrowhead). d The frontal third of the cricoid cartilage was resected, and the subglottic area was exposed (white arrowhead). e The glottis was divided into upper and lower portions (not shown in the figure due to the semi-sitting position). f Glottic closure by suturing the right and left vocal folds of both the upper and lower portions (not shown in the figure due to the semi-sitting position). g Reinforcement of the closure site with the left sternohyoid muscle (white arrowhead). h Creation of a permanent tracheostoma.
Color version available online
We reported the cases of 2 patients with HNC who underwent AP surgery for improvement of QOL under local anesthesia as a means of palliative care. Several studies have reported an increased risk of dysphasia and aspiration in patients with HNC [1, 5]. AP surgery for patients with HNC as a means of palliative care may improve their QOL by reducing suction frequency and intratracheal stimulation by the cannula, especially when a tracheal cannula is already in place, impairing speech [2]. A few cases of AP surgery under general anesthesia in patients with HNC have been reported [2, 3, 6], but there have been no reports of AP surgery under local anesthesia.
As patients with HNC under terminal care are in poor respiratory and/or cardiac condition and have a low nutrient status, it is assumed that they cannot endure AP surgery under general anesthesia. In the present cases, we judged AP surgery under general anesthesia insupportable because of the patients’ poor respiratory function. However, even in such patients, we believe that AP surgery under local anesthesia could improve their QOL. Moreover, AP surgery under local anesthesia was reported to improve the QOL of patients by decreasing dysphagia, avoiding discomfort sensation by tracheal cannula placement, and reducing suction frequency [2, 7]. In addition, such patients can opt to receive medical treatment at home by reducing suction frequency and the possibility of developing aspiration pneumonia.
This is important because being able to receive home care is considered of great importance to patients under palliative care.
Patients with HNC often have a scar on the neck due to past surgery, contracture of the neck, and deformation of the laryngopharynx after treatment for cancer. Thus, the treatment of HNC may result in swallowing dysfunction including impairment of pharyngeal contraction, insufficient laryngeal elevation, and poor opening of the upper esophageal sphincter. It should be noted that AP surgery can only prevent aspiration but not improve swallowing function or ensure resumption of oral intake. Therefore, we need to preoperatively explain to the patients that AP surgery will not improve swallowing function. Further, we should consider the possi- bility that the patients may permanently lose their voice. The loss may not be of major impor- tance because most patients with HNC who require AP surgery have already undergone tracheostomy and are unable to vocalize.
The other important advantage of AP surgery is that the tracheostoma can be preserved without a tracheal cannula. An indwelling tracheal cannula can cause discomfort due to endo- tracheal stimulation of the cannula, granulation formation inside the tracheal wall and around the tracheostoma, and tracheal inflammation [7], whereas a large permanent tracheostoma created through AP surgery could improve the patient’s status without requirement for a tracheal cannula and the associated discomfort. A large tracheostoma without cannulation after AP surgery is considered beneficial for patients who receive palliative care and could improve their QOL. In summary, as AP surgery for palliative care improves the QOL of patients with HNC, we should consider AP surgery as an optional treatment, taking into account the patients’ condition including the HNC prognosis.
Statement of Ethics
This study was approved by the Human Ethics Committee of the University of Tokyo (No. 2487) and complied with the amended Declaration of Helsinki. Written informed consent was obtained from the patients in this study to publish their cases (including images).
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
There are no funding sources to report.
Author Contributions
M.S.K. was involved in patient care and surgery, collected information, and drafted the manuscript. R.U.
conceived the study, was involved in patient care, surgery, follow-up and preparation of the imaging, and drafted the manuscript. T.G., T.S., A.T., Y.M., and T.N. were involved in patient care and surgery and critically revised the manuscript. T.Y. was involved in patient care and critically revised the manuscript.
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