Neck Surgery

1
Neck Surgery

• Presenters Jessica Drayer,
• Dan Elton

2
Anatomy of the neck
3
(No Transcript)
4

• Mr. Persingers favorite Long neck

5

• Justins and Levis favorite long neck
• Silly Mormons

6
The Cervical Spine

• C1-C7 (cervical vertebrae) C1 through C7 are the
  symbols for the cervical vertebrae, the upper 7
  vertebrae in the spinal column (the vertebral
  column).

7

• C1 is called the atlas. It supports the head and
  is named for the Greek god Atlas who was
  condemned to support the earth and its heavens on
  his shoulders.
• C2 is called the axis because the atlas rotates
  about the odontoid process of C2. The joint
  between the atlas and axis is a pivot that allows
  the head to turn. The axis bone serves as the
  axle about which the atlas (and the head) turn.

8

• C7 is sometimes called the prominent vertebra
  because of the length of its spinous process (the
  projection off the back of the vertebral body).

9
(No Transcript)
10
(No Transcript)
11

• Muscles - anteriorly, strap muscles connect the
  respiratory skeleton and sternum. There are also
  muscular attachments from the hyoid to the
  tongue, mandible, and styloid. The digastric
  muscle passes forward from the mastoid, attaches
  to the hyoid, then ascends to the anterior
  mandible. The sternocleidomastoid (SCM) divides
  the neck into anterior and posterior triangles.
  The posterior triangle is largely muscular. The
  anterior triangle which contains most of the
  vital structures, can be divided into smaller
  triangles by muscles.
• The anterior and posterior bellies of the
  digastric form the submandibular triangle. The
  submental triangle is in the midline, between the
  anterior bellies. The vascular or carotid
  triangle is inferior to the digastric and hyoid.
• The omohyoid is a small muscle, running at
  roughly 90 degrees to the SCM, from the hyoid to
  the scapula.

12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
Carotid Endarterectomy

• Preoperative evaluation
• Pt Hx Atherosclerosis, PAD, CAD, MI, TIAs, DM,
  RI, HTN Control BP
• High risk for postoperative hemodynamic
  instability neurologic deficits
• Beta-blocker, resting HR lt60
• Reasons to delay the surgery are uncontrolled HTN
  or DM, MI lt3 months
• Neurological evaluation
• History of events (stroke, TIAs)
• Cranial nerve evaluation
• Hypoglossal, Vagus, Recurrent Laryngeal, Marginal
  mandibular nerve

16
Carotid Endarterectomy

• Intraoperative management
• Monitor
• A-line
• 18-gauge IV line
• CVP (avoid contralateral carotid puncture)
• Cerebral perfusion monitor (if you have one)
• No evidence favor regional or general anesthesia
• Keep BP in the high normal range (up to 20 above
  baseline)

17
(No Transcript)
18
Regional anesthesia

• Superficial deep cervical plexus block
  (anterior branch of C2-4)
• Advantage
• Repeated neurologic evaluation
• ?need of shunting
• ? Hospital stay
• ? perioperative cardiac morbidity stroke

19
Disadvantage to regional anesthesia

• The possibility of seizure or loss of
  consciousness with carotid cross clamping
• Poor access to the airway (2-3 need for
  conversion to GA)
• Phrenic superior laryngeal nerve block
• High spinal

20
General anesthesia

• Advantage
• Control of airway ventilation
• Cerebral protection
• ?cerebral metabolic rate gt?blood flow
• Thiopental against focal ischemia
• Maintain normocapnia
• Need neurologic monitor

21
Postoperative care

• Cranial nerve and patient assessment
• Transient, resolve within 6 mo.
• Hypoglossal n tongue deviation
• Recurrent laryngeal n dysphagia, hoarseness
• Recurrent stenosis
• Duplex imaging at 30d, 6mo, then annually
• Lifelong aspirin
• Risk factor modification

22
Anterior Cervical Fusion/Fixation

• Upper Cervical (C1-C2) Spine
• Transoral Approach
• Anterolateral Retropharyngeal Approach
• Mid and Lower Cervical Spine
• Anterolateral Retropharyngeal Approach

23
Transoral Approach

• Special Considerations
• Dingman retractor will be used to facilitate
  surgical accessbeware of lips b/t retractor and
  teeth.
• Use a wire-reinforced ETT to allow maximal
  bending of tube to remove from field and prevent
  compression from retractor.
• Some prefer routine tracheostomy.
• May also use nasal ETT.
• Fire precautionsi.e. FiO2 lt30.
• High risk of infection.

24
Anterolateral Retropharyngeal Approach

• Special Considerations
• Lower risk of infection versus transoral
  approach.
• Increased risk of damage to recurrent laryngeal
  nerve leading to vocal cord paralysis
• Left side approach has less risk of injury, since
  the left recurrent laryngeal nerve has a longer
  course in the tracheoesophageal groove and is
  thus less susceptible to injury from
  overstretching during retraction
• Increased risk of vascular injury

25
Posterior Cervical Fusion/Fixation

• Upper Cervical Spine
• Prone with head in tong traction or pins
• Posterior Midline Incision
• Possible FOI or glidescope
• SSEPs Monitoring
• Mid and Lower Cervical Spine
• Prone or sitting, head with pin fixation or
  horseshoe headrest
• Posterior Midline Incision
• Possible FOI or glidescope

26
Anterior and Posterior Cervical Fusion/Fixation

• Preoperative Evaluation
• Pt Hx Stable vs. Unstable Fracture, Neck Pain,
  Neck ROM, Neurological Deficits, Ventilatory
  Impairments
• Acute fractures with spinal cord trauma at the T1
  level will be paraplegic, while fractures above
  C5 may be quadriplegic and have loss of phrenic
  nerve function.
• Thorough documentation of preop sensory and motor
  deficits is very important!
• Tests CT, MRI, Hct, other tests per HP

27
Anterior and Posterior Cervical Fusion/Fixation

• Intraoperative Management
• Monitors
• Standard Monitors ? /- CVP (sitting position)
• Arterial line ? /- Doppler (sitting position)
• Foley Catheter
• IV Access
• 16-18 gauge x 1, 2 preferable
• Positioning
• Supine Cervical traction, shoulder roll, head
  extended
• Prone Foam face pillow, check eyes, ears, nose
• Sitting VAE monitoring (?ETCO2,?ETN2, ?BP,
  Dysrhythmias)

28
Anterior and Posterior Cervical Fusion/Fixation

• Anesthetic Technique
• GETA
• Induction Stable neck--standard layngoscopy.
  Unstable neck or transoral approach---FOI.
  Standard IV induction
• Maintenance Standard. Neuromuscular blockade is
  helpful with insertion of the Dingman retractor.
  Further use of relaxant is not usually necessary,
  esp. if SSEPs in use. Keep MAP gt70mmhg.
• Emergence Desirable to leave ETT in place until
  pt is able to follow commands and protect airway.
  
• Immediate airway obstruction 2 edema or
  recurrent laryngeal nerve damage may occur
• Assess patency by deflating ETT cuff to see if pt
  can breathe around tube

29
Anterior and Posterior Cervical Fusion/Fixation

• Postoperative Management
• Monitor for airway obstruction due to edema
• Monitor for any neurological deficits
• Pts usually go to PACU then to room with the
  exception of the anterior upper cervical
  procedures, which will go to the ICU for close
  monitoring.

30
Thyroidectomy
31
Thyroidectomy

• Supine position with neck extended.
• Transverse Cervical Incision
• Resection can be total, subtotal (lobe isthmus
  /- partial remaining lobe), or lobar.
• Risk of damage to recurrent laryngeal nerve

32
Thyroidectomy

• Preoperative Evaluation
• Hyperthyroidism
• TFTs ? T4,?T3, Normal or ? TSH
• Sx fatigue, sweating, intolerance to heat, ?HR,
  ?BP, ?pulse pressure, ?Temp, wt. loss/gain,
  thyroid goiter, and exophthalmos.
• May be taking propylthiuracil (PTU),
  methimazole, potassium, sodium iodide, beta
  blockersshould be continued through a.m. of
  surgery
• Euthyroid state is ideal prior to elective
  surgery
• Beware of tracheal compression with large
  goiters.
• Thyroid Storm is a life-threatening exacerbation
  of hyperthyroidism that can occur during stress
• Tests ECG, ECHO, CBC, BMP, others per HP

33
Thyroidectomy

• Thyroid Storm
• Clinical Manifestations hyperthermia,
  tachycardia, HTN, anxiety, altered mental state,
  myopathy
• Onset is usually 6-24 post-op, but can occur
  intra-op. Can be mistaken for MH.
• Unlike MH, it is not assoc. w/ muscle rigidity,
  elevated CPK, or marked degree of lactic or resp.
  acidosis
• Trtmt ?FiO2, IV hydration, electrolyte
  replacement, cool pt, PTU (200-250mg po q 4h),
  sodium iodide (1-2.5g IV), propanolol (0.25-1mg
  IV q 5min) and/or esmolol (50-300mcg/kg/min),
  hydrocortisone (100mg IV q 8h) or decadron (4mg
  iv q 24h)

34
Thyroidectomy

• Hypothyroidism
• TFTs ?T4, ? or normal T3, ?TSH
• Sx intolerance to cold, fatigue, wt. gain/loss,
  ?muscle reflexes, ?mentation, ?HR, ?SV,
  ?contractility, ?CO, and?Temp.
• May have difficult airway d/t obesity, large
  tongue, short neck, goiter
• Euthyroid state is ideal before elective surgery
  but mild to moderate hypothyroidism is not an
  absolute contraindication
• Myxedema coma occurs d/t severe hypothyroidism
  and is a medical emergency
• Tests ECG, ECHO, CBC, BMP, others per HP

35
Thyroidectomy

• Myxedema Coma
• Clinical Manifestations stupor/coma,
  hypothermia, hyponatremia, hypoventilation with
  hypoxemia, ?HR, ?BP
• Trtmt Intubation and mechanical ventilation,
  volume expansion (cautiously), inotropes, pacing,
  rewarming, careful correction of ?Na, L-thyroxine
  (T4) (400-500mcg iv load, 50-200mcg iv qd), or
  tri-iodothyronine (T3) (12.5mcg iv q6-12h),
  hydrocortisone (100-300mg iv qd).

36
Thyroidectomy

• Intraoperative Management
• Monitors
• Standard
• IV Access
• 18 gauge x 1
• Positioning
• Supine with neck extended
• Eye Protection

37
Thyroidectomy

• Intraoperative Management GETA
• Induction
• Hyperthyroid adeq. anesthetic depth to avoid
  sympathetic response to stimulation. Avoid
  agents that stimulate SNS (i.e. ketamine,
  pancuronium)
• Hypothyroid more sensitive to hypotensive
  effects of anesthetic agentsetomidate or
  ketamine maybe better choice
• Euthyroid standard
• Maintenance
• MAC is unaffected by thyroid state
• If using laser, will use NIM tube.
• Need to maintain temp, esp. in hypothyroid pts.
• Emergence
• Beware of airway obstruction 2 recurrent
  laryngeal nerve damage, hematoma formation

38
Thyroidectomy

• Postoperative Management
• Assess for recurrent laryngeal nerve damage
• B/L unable to speak
• U/L hoarseness
• Ability to phonate e proper vocal cord
  function
• Hematoma w/airway compromise
• Rapid re-intubation
• Re-open incision and drain blood
• Acute Hypoparathyroid state
• Ca Gluconate iv
• Thyroid Storm

39
Parathyroidectomy

• Pt positioned supine with neck extended.
• Transverse Cervical Incision
• Methylene Blue or radioactive tracers may be
  placed to ID tissue
• Risk for damage to recurrent laryngeal nerve

40
Parathyroidectomy

• Preoperative Evaluation
• Pt Hx Hypercalcemia, HTN, electrolyte
  abnormalities, volume depletion,
  pheochromocytoma (MEN-2), muscle weakness
• Tests ECG, CBC, BMP, others per HP
• Continue all meds that lower hypercalcemia
  unless Ca levels have normalized.

41
Parathyroidectomy

• Intraoperative Management
• Technique GETA
• Induction Standard. Ensure adequate volume
  status.
• Maintenance Standard. Avoid hyper/hypoventilatio
  n
• Acidosis leads to ?Ca levels
• Alkalosis leads to ?Ca levels
• Emergence Assess for airway compromise 2
  hematoma, laryngeal edema, recurrent laryngeal
  nerve damage.

42
Parathyroidectomy

• Postoperative Management
• Hypocalcemia
• Sx parathesias, muscle spasms, tetany,
  laryngospasm, bronchospasm, apnea
• Tx 10-20ml Calcium gluconate 10 over 10 min
• Recurrent laryngeal nerve damage
• Hematoma w/ airway compromise

43
Radical Neck Dissection

• Pt supine with head turned.
• Table turned 180.
• Various neck incisions.
• Risk of damage to facial nerve, recurrent
  laryngeal nerve, phrenic nerve.
• May require tracheostomy

44
Radical Neck Dissection

• Preoperative Evaluation
• Pt Hx Usually have a hx of smoking and ETOH use
  bronchitis, COPD, HTN, assess for carotid
  stenosis, radiation therapy.
• Tests CXR, ECG, CBC, BMP, TS for 2units PRBCs,
  Carotid studies, others per HP

45
Radical Neck Dissection

• Intraoperative Management
• Monitors
• Standard ?Foley
• Arterial line ? /- CVP
• IV Access
• 16 gauge X 2
• Positioning
• Supine w/ head turned and elevated 30 to control
  bleeding
• Monitor for VAE

46
Radical Neck Dissection

• Intraoperative Management
• Induction Depends on degree of airway compromise
  and anatomical location of lesioncould perform
  standard laryngsocopy, awake FOI, or
  tracheostomy. Standard IV induction.
• Maintenance NMBD are usually avoided to allow
  identification and preservation of nerves.
  Controlled hypotension for control of blood loss.
  Monitor fluids admin to prevent edema and
  congestion of flap. If profound bradycardia
  occurs with dissection around carotid bulb, ask
  to stop stimulation, treat with robinul or
  atropine.
• Emergence Needs to be smooth. Assess for
  possible embolic stroke.

47
Radical Neck Dissection

• Postoperative Management
• Treat HTN and ?HR that may occur from carotid
  sinus denervation or pain
• Assess for facial nerve injury facial droop,
  recurrent laryngeal nerve injury, and phrenic
  nerve injury
• Assess for airway compromise

48
Tracheostomy

• Pt positioned with head extended.
• Incision made at transverse crease midway b/t
  thyroid notch and suprasternal notch

49
Tracheostomy

• Preoperative Evaluation
• Pt Hx HTN, smoking hx, cause for respiratory
  insufficiency, if intubated-vent settings.
• Tests CXR, ECG, CBC, others per HP

50
Tracheostomy

• Intraoperative Management
• Monitors Standard
• IV Access 18 gauge x 1
• Positioning Supine with head extended.

51
Tracheostomy

• Intraoperative Management
• Induction already intubated (converted to GA),
  standard laryngoscopy, awake FOI. Standard IV
  induction.
• Maintenance Full muscle relaxation. Keep FiO2
  lt30 if tolerated, have tapes ready when time
  comes to pull ETT back, deflate cuff when asked
  by surgeon and pull ETT back (NOT OUT), once
  trach in place confirm ETCO2, BBS, and airway
  pressures.
• If inability to insert trach, re-intubate with
  ETT, FOB, or jet-ventilation
• Airway fire precautions!!
• Emergence Continue on ventilatory support to ICU

52
Tracheostomy

• Postoperative Management
• Have airway pack for transport to ICU
• If trach tube pops outreintubate orally.
• Assess for occlusion of trach tube 2 secretions,
  mucus plug, blood, positioning of tube against
  tracheal wall.

53
Case study

• 52 year old male presents complaining of neck
  pain. Patient reports feeling lightheaded while
  urinating. States he reached back to steady
  himself on the towel rack and the next thing he
  remembers he is lying in the shower stall with
  his neck "crunched up" on his chest. Patient
  proceeded to pick himself up, reporting neck
  pain, and continued with his morning activities.
  When the pain did not go away after 60 minutes he
  had his wife drive him to the ED and he walked in
  for evaluation. Patient initially denied any loss
  of consciousness but on further questioning did
  not have full recall of events, denies any
  numbness or tingling, denies bowel or bladder
  incontinence.

54

• VS HR 60, RR 14, BP 110/70, SaO2 100 room air
• Head CT negative for intracranial bleed, C-spine
  series is as follows

55
(No Transcript)
56

• DX This patient has a bilateral facet
  dislocation (unstable injury) of C4 caused by
  disruption of the posterior ligamentous complex
  during distraction (when patient lost
  consciousness) and hyperflexion, and a wedge
  fracture (stable) of C5.
• The plan is to perform a posterior cervical
  fusion.
• What is our anesthesia plan?

57

• Monitors
• Standard Monitors ? /- CVP (sitting position)
• Arterial line ? /- Doppler (sitting position)
• Foley Catheter
• IV Access
• 16-18 gauge x 1, 2 preferable
• Positioning
• Prone Foam face pillow, check eyes, ears, nose
• Sitting VAE monitoring (?ETCO2,?ETN2, ?BP,
  Dysrhythmias)
• Anesthetic Technique
• GETA
• Induction Unstable neck FOI or glidescope.
  Standard IV induction.
• Maintenance Standard. Neuromuscular blockade is
  not usually necessary, esp. if SSEPs in use. Keep
  MAP gt70mmhg

58

• Emergence Leave ETT in place until pt is able to
  follow commands and protect airway.
• Assess patency by deflating ETT cuff to see if pt
  can breathe around tube
• Postoperative Management
• Monitor for airway obstruction due to edema
• Monitor for any neurological deficits
• Pts usually go to PACU then to room.

59
Questions

• 1.The most common nerve injury in patients
  undergoing subtotal thyroidectomy is damage to
  the?
• A. internal laryngeal nerve
• B. recurrent laryngeal nerve
• C. ulnar nerve
• D. common peroneal nerve

60
Answer

• B is correct. The most common nerve injury
  associated with subtotal thyroidectomy is damage
  to the recurrent laryngeal nerve. Unilateral
  surgical damage results in hoarseness and a
  single paralyzed vocal cord. Bilateral damage
  results in aphonia and total airway obstruction
  requiring mechanical ventilation. The patency of
  vocal cord function can be assessed
  postoperatively by viewing the cords through a
  fiberoptic scope or by having the patient say 'e'.

61
Question

• 2.During general anesthesia for a
  parathyroidectomy for relief of
  hyperparathyroidism, you should monitor the ECG
  closely for?
• A Prolonged QT Interval
• B. Shortened QT interval
• C. Shortened PR Interval
• D. None of the above

62
Answer

• The correct answer is B. Hyperparathyroidism
  results in hypercalcemia and hypophosphatemia
  which can distort the ECG resulting in a
  shortened QT Interval and prolonged PR interval.

63
Question

• 3.You are performing a general anesthetic for a
  patient undergoing dissection of the lower neck
  for malignancy when you notice a 20 drop in
  oxygen saturation, diminished ECG amplitude, a
  drop in blood pressure, and diminished breath
  sounds. Based on these findings, you suspect?
• A. Inadvertent migration of the endotracheal out
  of the trachea and into the pharynx
• B. Pulmonary embolus
• C. Pneumothorax
• D. Malfunction of the anesthesia monitors

64
Answer

• C is Correct. Pneumothorax is a significant risk
  of dissection of the lower neck and may present
  with a decrease in oxygen saturation, diminished
  breath sounds, diminished ECG amplitude, a drop
  in blood pressure, increased CVP, wheezing, and
  dullness on percussion of the chest.

65
Question

• 4. You are performing general anesthesia for a
  patient undergoing a thyroidectomy and has a hx
  of hyperthyroidism. All of a sudden the pt
  exhibits hyperthermia, tachycardia and HTN. There
  are no signs of muscle rigidity or acidosis.
  Which medications would you NOT use to treat this
  clinical situation?
• A. PTU
• B. Dantrolene
• C.Sodium Iodide
• D. Propanolol

66
Answer

• B. Dantrolene is correct. Dantrolene is used to
  treat MH. This pt is exhibiting symptoms of
  Thyroid Storm. MH presents with hypercarbia,
  tachycardia, hyperthermia, muscle rigidity and
  acidosis.

67
Question

• 5. Which induction agent is the best choice for
  the moderate hypothyroid patient?
• A. Propofol
• B. Thiopental
• C. Etomidate

68
Answer

• C. Etomidate is correct because the hypothyroid
  patient to more sensitive to the hypotensive
  effects of anesthetic agents and etomidate has
  minimal effects on the cardiovascular system.