Should a patient with tonsillar cancer be intubated?

Management of Airway in Patients with Tonsillar Cancer

Patients with tonsillar cancer should be intubated early with an awake technique or have a surgical airway established under controlled conditions due to the high risk of complete airway obstruction.

Risk Assessment for Airway Management in Tonsillar Cancer

• Tonsillar cancer patients should be considered at high risk for difficult intubation due to potential airway obstruction, tissue edema, and limited mouth opening 1, 2
• Previous radiation therapy to the head and neck region causes fibrosis and reduced tissue mobility, further complicating airway management 2
• Complications of tonsillar cancer including bleeding, infection, and tumor mass can lead to acute supraglottitis and imminent airway compromise 2
• All patients admitted to intensive care units must be considered at risk of complicated intubation, with tonsillar cancer representing a particularly high-risk group 1

Airway Management Options

Preferred Approach

• For patients with known difficult airways due to tonsillar cancer, awake techniques should be considered first-line to maintain spontaneous ventilation 1, 3
• Awake fiberoptic intubation is regarded as the gold standard for securing difficult airways in these patients, though it is seldom used in critically ill patients 1
• Videolaryngoscopy, including awake techniques, has become a viable alternative in experienced hands 1

Surgical Airway Considerations

• Elective tracheostomy under local anesthesia should be strongly considered for patients with significant airway compromise from tonsillar cancer 2
• Conscious sedation should be avoided in these cases due to the potential for complete airway obstruction 2
• Establishing a surgical airway under controlled operating conditions is optimal for managing imminent airway obstruction in oropharyngeal cancer 2

Complications to Anticipate

• Blood, secretions, and tumor tissue in the airway can hamper both fiberoptic visualization and video-laryngoscopy 1
• Awake techniques may precipitate complete airway obstruction from over-sedation, topical anesthesia, laryngospasm, or bleeding 1
• Trismus and tissue edema from acute infection or radiation fibrosis can make the glottis and surrounding structures nearly impossible to visualize during direct laryngoscopy 2
• Tonsillectomy complications include bleeding (0.1-3% rate), trauma to surrounding structures, and respiratory compromise 1

Special Considerations for Extubation

• Extubation of known difficult airways should only be performed during daytime hours 1
• Airway exchange catheters (AECs) are recommended for extubation of difficult airways to facilitate reintubation if needed 1
• After extubation, the patient should be observed carefully with reintubation anticipated until stable 1
• CPAP, NIV, or HFNO can reduce reintubation rates in high-risk patients 1

Rescue Techniques for Failed Intubation

• If conventional intubation fails, wire-guided retrograde intubation should be considered early before proceeding to a surgical airway 4
• Retrograde intubation may be particularly effective as it can stent open an otherwise occluded airway 4
• For "can't intubate, can't ventilate" scenarios, prompt transition to front of neck access (FONA) with a scalpel technique and vertical incision is recommended 1

Conclusion

The management of tonsillar cancer patients requires careful airway assessment and planning. Given the high risk of airway compromise and difficult intubation, these patients should be intubated early with awake techniques or have a surgical airway established under controlled conditions. The decision should not be delayed, as complications from tonsillar cancer can rapidly progress to complete airway obstruction.