ANAESTHESIA FOR HEMIMANDIBULECTOMY IN PATIENTS WITH MALIGNANT DISEASE

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1 Brit. J. Anaesth. (1968), 40, 451 ANAESTHESIA FOR HEMIMANDIBULECTOMY IN PATIENTS WITH MALIGNANT DISEASE BY M. J. BASCOMBE AND C. B. LEWIS SUMMARY An account is given of fifty cases of hemimandibulectomy, thirty-three of whom had block dissection of the neck. Problems which the anaesthetist is likely to meet in patients with malignant disease undergoing this operation are: respiratory and cardiovascular disease, poor nutrition and hypovolaemia, the local sequelae of intensive pre-operative radiotherapy, and intra-oral and pharyngeal suppuration. A suitable method of anaesthesia and controlled hypotension is described. Complications occurring during the operation were few, but included two cases of parasympathetic reflex disturbance. Postoperative complications included respiratory obstruction, persistent hypotension and reactionary haemorrhage following the use of controlled hypotension. The indications for tracheostomv in these patients are discussed. The Commando operation, i.e. hemimandibulectomy with radical block dissection of the neck, is an uncommon operation. Within recent years fifty patients have been treated by hemimandibulectomy performed by one surgeon using the same technique at the Royal Marsden Hospital. Thirtythree of these patients had either suprahyoid or Crile* block dissections, usually with removal of part of the tongue or other tissues of the mouth, cheek or lip. Of the remainder, two had previous Crile block dissection. In view of the scarcity of literature on the subject and the low morality in this series the opportunity has been taken to review the fifty cases with special reference to anaesthesia. In 88 per cent the lesion was a primary squamouscelled carcinoma of the buccal cavity, oropharynx or lower lip. The remainder suffered from primary malignant tumours of the nose, mandible or submandibular salivary gland (table I). ANAESTHETIC CONSIDERATIONS Anaesthesia for radical surgery of the head and neck has been discussed frequently (Noble, 1960; Martin and Gould, 1963; Wester, 1964). Prob- * Dissection and removal from the supraclavicular region upwards of the stemomastoid, internal jugular vein, fat, fascia, lymph nodes and submandibular salivary gland en bloc The vagus nerve and carotid artery are preserved. TABLE I Site and nature of lesions. Lesion Carcinoma of buccal cavity or lower lip 88 Squamous cell carcinoma of nose, spread to regional nodes 4 Malignant tumours of mandible 6 Carcinoma of submandibular salivary gland 2 Total 100 lems particularly associated with malignant disease of the buccal cavity in this series were: (1) The sequelae of intensive pre-operative radiotherapy (received by all but two patients). These are: a high incidence of trismus, brawny induration of the soft tissues of the neck, and limitation of movement of the cervical spine. (2) Intra-oral and pharyngeal suppuration. (3) Extensive tissue exposure and dissection during the operation. Adequate pre-operative preparation rninimized the problems of poor nutrition and hypovolaemia. The age distribution is shown in figure 1. The average age was 60 years; 86 per cent were over 50 years; 72 per cent were male; 74 per cent had some other disease, the commonest being associated with the respiratory and cardiovascular systems (table II).

2 452 BRITISH JOURNAL OF ANAESTHESIA No. of cases TABLE II Pre-operatwe disease Disease Chronic bronchitis, emphysema Hypertension Other ' 4 ' Age In years FIG. 1 Age distribution of fifty cases of hemimandibulectomy. One patient had a history of cardiac infarction 15 years before operation; one had gross aortic incompetence; three had left ventricular hypertrophy. One male aged 79 years who died 13 months after operation was found postmortem to have a bronchogenic carcinoma, bronchiectasis, emphysema, left ventricular hypertrophy, chronic duodenal ulcer and an aneurysm of the circle of Willis. It was not possible to determine the incidence of sub-clinical cardiovascular disease. Length of operation varied from 60 to 240 minutes (average 123 minutes). METHODS Premedication consisted of an opiate or pethidine with hyoscine or atropine. Thiopentone was used for induction. In the early cases, before the introduction of suxamethonium, intubation was performed under thiopentone. Later all patients were intubated with the aid of suxamethonium. A cuffed nasotracheal was used and the pharynx packed. Trismus and brawny induration of the neck often made intubation difficult but no patient needed pre-operative tracheostomy or intubation under local anaesthesia. Anaesthesia was maintained with nitrous oxide, oxygen and trichloroethylene in the earlier cases. Later, the majority were given nitrous oxide, oxygen and halothane. Controlled hypotension was used in 68 per cent. Hypotension was induced with a 0.1 per cent trimetaphan (Arfonad) drip, aided by a degree head-up tilt and halothane. Two patients were given hexamethonium. The systolic blood pressure was lowered enough to produce a useful reduction of bleeding at the site of operation. A minimum of mm Hg was considered safe and was adequate in most cases. Blood loss was estimated by observation of swabs and the contents of the suction bottle and replaced towards the end of the neck dissection unless the condition of the patient or excessive blood loss indicated earlier replacement. Tracheostomy was performed at the end of the operation if indicated (vide infra). RESULTS Operating conditions. Operating conditions were generally good. Blood replacement varied from nil to (average ); 8 per cent needed 2 1. or more. In one case copious bleeding occurred and was needed. Another had troublesome bleeding from divided muscles near the base of the skull.

3 ANAESTHESIA FOR HEMIMANDIBULECTOMY 453 Complications during anaesthesia. Parasympathetic reflex disturbance was observed in two cases. In one patient the blood pressure suddenly fell when the carotid sheath was opened, and in the other when traction was applied to the right vagus nerve. Controlled hypotension was in use in both patients; neither had pre-operative hypertension. This incidence (4 per cent) is comparable with the four episodes reported by Noble (1960) in 125 cases of maxillofarial and radical neck surgery. We have not seen parasympathetic reflex disturbance following the use of diathermy near the vagus nerve. Other possible complications, such as air embolism (Martin and Gould, 1963) or pneumothorax (Schweizer, 1955) were not observed. Early postoperative complications. Fourteen per cent developed respiratory obstruction in the early postoperative period. Persistent hypotension (systolic blood pressure more than 40 mm Hg below the pre-operative level for more than 6 hours) occurred in 6 per cent of cases. These will be discussed later. Other complications included wound haematoma (one case) which needed evacuation, one instance of morphine overdose and two of minor haemorrhage from tracheostomy wounds during the first postoperative 24 hours. Pneumothorax or pneumomediastinum were not observed though cases may have occurred and not been diagnosed. Thomas and Hux (1957), commenting on four cases in thirty-seven radical neck dissections, state that these complications are probably more frequent than is realized, because with minimal to moderate involvement there may be no obvious clinical manifestations. Partial respiratory obstruction, by increasing the negative intrathoracic pressure during inspiration, is an important factor in the production of pneumomediastinum during dissection in the neck (Schweizer, 1955). The absence of clinically obvious pneumomediastinum and pneumothorax in our cases may be due partly to the care taken in maintaining a free airway during the operation. DISCUSSION This group of patients had a high average age and high incidence of pre-operative disease. Some were in poor general condition. All but two had TABLE Early postoperative Complication Persistent hypotension Respiratory obstruction Other Total III complications recently completed a 3-month course of radiotherapy. There was one death. This occurred in a woman of 65 years who smoked heavily. The pre-operative chest X-ray showed some consolidation below the right hilum and partial collapse at the left base. In April 1961 a well differentiated squamous-cell carcinoma in the anterior part of the floor of the mouth was excised together with the adjacent mandible under hypotensive anaesthesia. No block dissection was performed. One litre of blood was replaced. Twelve hours after operation she became restless and complained of difficulty in breathing. She was given a benzedrine nasal spray and improved. On the third postoperative day she repeatedly stated that she was unable to breathe. She was not cyanosed; her pulse was 96 beats/min and regular. She became confused during the following night, and collapsed and became cyanosed early next morning. Respiratory efforts were weak and her pulse rapid and feeble. Pharyngeal suction slightly improved her respiration but she died before more active treatment was possible. Postmortem examination showed a large amount of mucus in the left bronchial tree, a large plug causing collapse of the left lower lobe. Death might have been prevented had more active treatment (including tracheostomy) been instituted when signs of respiratory insufficiency first became apparent. Anaesthesia. The method commonly used at present is to induce anaesthesia with thiopentone mg and to pass an endotracheal with the aid of suxamethonium mg. A cuffed nasotracheal is used and a pharyngeal pack inserted. Anaesthesia is maintained with 50 per cent nitrous oxide in oxygen, halothane per cent from a Fluotec vaporizer, respiration being spontaneous. A Magill attachment (Mapleson type A) is used, the total fresh gas flow being 6-8 l./min. In this series it has proved a safe and simple method, producing, with controlled hypotension, acceptable operating conditions. Controlled hypotension. Some dissections would have been extremely difficult without the aid of controlled hypotension. A trimetaphan drip together with halothane and head-up tilt gave good and reasonably consistent results. The average blood replacement of

4 454 BRITISH JOURNAL OF ANAESTHESIA is high when compared with that in a similar group of 100 major head and neck procedures reported by Conley, Hicks and Jasaitis (1965), in which, using a 0.1 per cent trimetaphan drip, the systolic arterial pressure was reduced to a minimum of 55 mm Hg. The average blood replacement was slightly more than 1 unit (500 ml). In their series two patients suffered cerebrovascular accidents with resultant paresis and in a third cardiac arrest occurred during the operation; this was treated successfully. Though blood loss was high in our series, operating conditions were acceptable and no major complications occurred. For these reasons the higher minimum systolic B.P. (80-90 mm Hg) would seem to be preferable. Complications of controlled hypotension. Persistent postoperative hypotension. Table IV indicates that the incidence of postoperative hypotension following the use of trimetaphan (3 per cent) was no more than that following the use of a non-hypotensive technique. Postoperative No. 32 Persistent postoperative hypotension 1 Reactionary haemorrhage 2 TABLE IV complications related to controlled hypotension. Trimeta- Hexa- No hypophan methonium tension Reactionary haemorrhage. This occurred in two cases. In both it followed the use of trimetaphan. In one patient tracheal compression by a haematoma caused respiratory obstruction for which emergency tracheostomy was required 2 hours after operation. There were no other major complications which could be attributed to controlled hypotension. The low incidence helps to justify the careful use of controlled hypotension during hemimandibulectomy and radical neck dissection. Postoperative respiratory obstruction. The causes and treatment of postoperative respiratory obstruction in this series are shown in table V. In all patients except case 7 the operation performed was hemimandibulectomy with block dissection. Suprahyoid block dissection was performed in five cases and Crile block dissection in one. Table VI shows the number of patients subjected to either Crile or suprahyoid block dissection and indicates: (1) The relative infrequency of elective tracheostomy after suprahyoid block dissection. (2) The high incidence (38 per cent) of postoperative respiratory obstruction following without tracheostomy. (3) The absence of postoperative respiratory obstruction in those patients on whom elective tracheostomy was performed. Case Operation 1 L. hemimandibulectomy; 2 R. hemimandibulectomy; R. Crile dissection 3 L. hemimandibulectomy; 4 R. hemimandibulectomy; 5 L. hemimandibulectomy; 6 R. hemimandibulectomy; 7 Excision medial part of mandible plus adjacent floor of mouth TABLE V Postoperative respiratory obstruction. Cause of obstruction Kinked, blocked or displaced nasotracheal Removal of nasotracheal Removal of nasotracheal Pressure on trachea from gross o:dema Pressure on trachea from haematoma Mucus in pharynx Tenacious mucus in trachea and bronchi; L. lower lobe collapse Postoperative interval 14 hours 5 hours 6 hours 12 hours 2 hours First postoperative night 3.5 days Treatment Removal of and aspiration Nasotracheal replacrd Tube replaced; tracheostomy next ajn. Emergency tracheostomy Emergency tracheostomy; evacuation of clot Aspiration Died before treatment possible

5 ANAESTHESIA FOR HEMIMANDIBULECTOMY 455 TABLE VI Relation of postoperative respiratory obstruction to type of dissection and tracheostomy. Crile Suprahyoid Tracheostomy No tracheostomy Tracheostomy No tracheostomy No. 13 Postoperative respiratory obstruction 0 Though morbidity (Davis, Kretchmer and Bryce-Smith, 1953; Meade, 1961; Glas, King and Lui, 1962; Watts, 1963) and mortality (Head, 1961) from tracheostomy, particularly emergency tracheostomy (Rosen et al., 1963; McClelland, 1965), are high, the data in tables V and VI suggest that elective tracheostomy should be performed in all patients undergoing hemimandibulectomy with Crile or suprahyoid block dissection. If a tracheostomy is not performed, efforts to maintain a dear airway should be particularly energetic during the first 12 hours after operation. In the early days of this series the avoidance of a tracheostomy was considered something of a challenge by the anaesthetist and surgeon. Had the indications been more fully appreciated, especially with regard to suprahyoid block dissection, the postoperative morbidity might have been reduced and the one death avoided. ACKNOWLEDGEMENT These patients were all under the care of Mr. Michael Harmer at the Royal Marsden Hospital. His co-operation during the preparation of this paper is greatly appreciated! REFERENCES Conley, J., Hicks, R. G., and Jasaitis, J. D. (1965). Hypotensive anesthesia in surgery of the head and neck. Arch. Otolaryng., 81, 580. Davis, H. S., Kretchmer, H. E., and Bryce-Smith, R. (1953). Advantages and complications of tracheotomy. J. Amer. med. Ass., 153, Glas, W. W, King, O. J. jr., and Lui, A. (1962). Complications of tracheostomy. Arch. Surg., 85, 56. Head, J. M. (1961). Tracheostomy in the management of respiratory problems. New Engl. J. Med., 264, 587. Martin, J. T., and Gould, A. B. (1963). Anesthesia for operations on the head and neck. Surg. Clin. N. Amer., 43, 929. McClelland, R. M. A. (1965). Complications of tracheostomy. Brit. med. J., 2, 567. Meade, J. W. (1961). Tracheotomy: its complications and their management. New Engl. J. Med., 265, 519. Noble, A. B. (1960). Some aspects of anaesthesia for head and neck surgery. Canad. Anaesth. Soc. J., 1, 269. Rosen, Z., Romanoff, H., Zelig, S., and Borman, J. B. (1963). A critical review of tracheostomy with special emphasis on the new indications. Laryngoscope (St. Louis), 73, Schweizer, O. (1955). Complications of anesthesia during radical surgery about the head and neck. Anesthesiology, 16, 927. Thomas, C. G. jr., and Hux, R. L. (1957). The recognition and treatment of pneumothorax accompanying radical neck dissection. Surgery, 42, Watts, J. McK. (1963). Tracheostomy in modern practice. Brit. J. Surg., 50, 954. Wester, M. R. (1964). Safe anaesthesia for radical surgery of the head and neck. Int. Anesth. Clin., 2, 665. ANESTHESIE POUR HEMIMANDIBUL- ECTOMIE CHEZ DES PATIENTS AVEC MALADIE MALIGNE SOMMAIRE On rapporte 50 cas d'hemimandibulectomie, avec dans 33 cas une dissection en bloc de la nuque. Les problemes que l'anesthesiste peut rencontrer chez des patients avec maladie maligne qui subissent cstte operation, sont: troubles respiratoires et cardiovasculaires, malnutrition et hypovolemie, sequelles locales d'un radiothirapie preop6ratoire intensive, et suppuration intra-orale et pharyngeale. Une mithode adequate pour 1'anesthisie et Phypotension controlee est decrite. Des complications ne se sont pre'sentes que rarement durant l'ope^ation, dont 2 cas de troubles par reflexe parasympathique. Les complications postop6ratoires comprenaient obstruction respiratoire, hypotension persistente et hemorrhagie par reaction apres emploi de l'hypotension controls. Les indications de la tracheostomie chez ces patients sont discutees. ANASTHESIE WAHREND DER HEMIMANDI- BULEKTOMIE BEI PATIENTEN MIT EINEM BOSARTIGEM TUMOR ZUSAMMENFASSUNG Es wird von funfzig Fallen mit einer Mandibulektomie berichtet, wobei in dreiunddreifiig Fallen der Nacken teilweise mit entfernt wurdc. Schwierigkeiten, auf die der Anasthesist bei Patienten, die sich wegen eines malignen Tumors dieser Operation unterziehen, stofit, sind folgende: respiratorische und kardiovaskulare Erkrankung, schlechter Ernahrungszustand und Hypovolamie, die lokalen Folgeerscheinungen einer intensiven praoperativen Radiotherapie und intraorale und pharyngeale Eiterherde. Es wird ein geeignetes Anasthesieverfahren und eine Methode zur Kontrolle der Hypotension beschrieben. KompUkationen wahrend der Operation traten selten auf. Dazu zahlten jedoch zwei Falle mit einer parasympathischen Reflexstorung. Zu den postoperativen Storungen gehsrten Verlegung des Atemweges, anhaltende Hypotension und rcaktive Blutung im Anschlufl an die Behebung der Hypotension. Die Indikationen zur Tracheotomie bei diesen Patienten werden besprochen.