What the Anesthesiologist Should Know before the Operative Procedure
Vocal cord polyps most often result from either vocal cord trauma, such as endotracheal intubation, or misuse of a person’s voice. Vocal cord polypectomy is typically an outpatient elective procedure. The polyps are often pedunculated unilateral masses located on the true vocal cords and are believed to occur from a ruptured capillary in the lamina propria of the vocal cord, resulting in a thickened epithelium over a fibrin stromal matrix.
Patients are typically male, have a history of aspirin or anticoagulant use, and present with vocal fatigue or hoarseness that has worsened or become more frequent. Vocal cord polyps are traditionally treated with microsurgery, although hemorrhagic polyps can be treated in the office setting using laser technology.
1. What is the urgency of the surgery?
What is the risk of delay in order to obtain additional preoperative information?
On rare occasions, vocal cord polypectomy can be a true emergency if the polyp obstructs the airway and causes respiratory distress. In the case of acute airway obstruction, the patient must immediately go to surgery. In addition to routine questions, the anesthesiologist should query the patient about what exacerbates the respiratory distress, for example, position, as well as what alleviates it.
Due to the airway obstruction, the operating room should be set up with all equipment that might be required to secure the airway, including a tracheostomy.
2. Preoperative evaluation
Due to the elective nature of vocal cord polypectomy, a thorough preoperative evaluation is often feasible. A history and physical examination should be performed and the extent of airway obstruction secondary to the vocal cord polyp should be determined.
The patient should be asked if there is difficulty breathing while lying flat or if there are factors such as exercise or tachypnea that exacerbate any dyspnea. Difficulty breathing in the supine position may be due to the vocal cord mass or other factors, including sleep apnea, and it is not always easy to discern the root cause.
Otolaryngologists evaluate the vocal cord polyps and cysts in several ways and the anesthesiologist should be aware of their findings. The first method is usually using a mirror placed in the posterior pharynx to visualize the vocal cords. If this does not yield enough information, otolaryngologists may perform a fiberoptic laryngoscopy.
While visualization of the vocal cord mass can provide a lot of information, it does not always give a complete picture of the relevant pathophysiology. To further evaluate the mass, videostroboscopy is often performed. Using a rigid or flexible endoscope, an accompanying strobe light allows the otolaryngologist to assess the structure and movement of the vocal cords.
This procedure helps to clarify the vocal cord mass’s impact on airway function. It is very helpful to the anesthesiologist to have this information because it can reveal if the mass is mobile and does not impede the airway or if it is solid and acts like a ball valve in the airway.
While vocal cord polypectomy is typically not a high-risk surgery, the patient should still be in optimal condition prior to proceeding with the procedure. Since a history of sleep apnea may be associated with difficulty in mask ventilating the patient, the likelihood of this condition should be assessed preoperatively.
One method is to ask if the patient has signs or symptoms of sleep apnea using the STOP BANG questionnaire. This is especially important since vocal cord polypectomy does not always require intubation and a general anesthetic with intermittent mask ventilation often suffices.
Patients with vocal cord lesions are often smokers and many of these patients have reactive airway disease that can be exacerbated by the procedure. Patients should be evaluated for the severity of the reactive airway disease, as well as for their medical management.
3. What are the implications of co-existing disease on perioperative care?
Perioperative risk reduction strategies
The patient should be NPO for 6 hours for solid food and may receive clear liquids up to 2 hours prior to the procedure under normal circumstances. If the patient has a comorbidity that would increase gastric emptying time such as diabetes mellitus, gastrointestinal motility disorders, symptoms of dysphagia, or gastroesophageal reflux disease, 8 hours of fasting for solid foods should be considered to decrease the risk of regurgitation and pulmonary aspiration.
Patients with inflammatory vocal cord lesions may be treated for presumed laryngopharyngeal reflux. Treatment includes histamine (H2)-blockers and proton pump inhibitors. These medications should be continued through the day of surgery.
An airway assessment needs to be conducted during the preoperative evaluation. Difficulty of intubation may change the anesthetic management of the patient.
a. Cardiovascular system
Vocal cord polypectomy requires rigid direct laryngoscopy for intubation of the patient and for the procedure itself. The stimulation from direct laryngoscopy often elevates the heart rate and blood pressure of the patient and increases the oxygen demand (MVO2) of the heart. The anesthesiologist must understand the patient’s cardiac physiologic state to be able to adjust the anesthetic to decrease the patient’s cardiac risk. If a stable patient has been medically managed and has a good functional capacity (METs > 4) then ACC/AHA guidelines state that one can proceed with surgery without further cardiac evaluation.
If the patient has active cardiac symptoms such as unstable coronary syndromes (unstable or severe angina, or recent MI), decompensated heart failure (new onset heart failure, or NYHA class IV), significant arrhythmias (Mobitz II or 3rd degree heart block, supraventricular tachycardia or atrial fibrillation with rapid ventricular rate, asymptomatic ventricular arrhythmia or bradycardia, new ventricular tachycardia), or severe valvular disease (severe aortic or mitral stenosis), surgery should be postponed until the patient has been optimized.
Direct laryngoscopy associated with vocal cord polypectomy can exacerbate reactive airway disease. Patients should be instructed to take their asthma medications the day of surgery. A beta-agonist may be given prior to induction of anesthesia to help bronchodilate the airway.
One of the causes of vocal cord lesions is described as laryngopharyngeal reflux. This can manifest itself as gastroesophageal reflux disease (GERD). If a patient has GERD, the anesthesiologist should consider an appropriate induction with endotracheal intubation. Renal disease is not associated with vocal cord polyps.
There are no remarkable neurologic conditions that affect vocal cord polypectomy. Patients with comorbidities in these areas should be treated according to their disease state.
There are no remarkable endocrine conditions that affect vocal cord polypectomy. Patients with comorbidities in these areas should be treated according to their disease state.
f. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
4. What are the patient's medications and how should they be managed in the perioperative period?
Medications, including prescription, over-the-counter, herbal supplements and vitamins, should be considered prior to surgery. Patients should be instructed to stop all herbal medications 7 days prior to surgery and nonsteroidal anti-inflammatory drugs (NSAIDs) at least 2 days prior to surgery. Most vitamins can be continued, but vitamin E and fish oil should be stopped 7 days prior to surgery to decrease the patient’s risk of intraoperative bleeding.
g. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
There are no medications commonly seen in patients undergoing vocal cord polypectomy that elicit concern.
h. What should be recommended with regard to continuation of medications taken chronically?
Medications for other comorbidities should be reviewed and discussed. Since the level of stimulation of the procedure can increase the heart rate and blood pressure, antihypertensive therapy should be continued through the day of surgery.
In patients with known coronary artery disease, it is very important to continue beta blockers. If the patient is on an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), you may want to consider holding this medication on the day of surgery. ACE inhibitors and ARBs cause acute drops in blood pressure in conjunction with anesthesia. This drop in blood pressure is more severe if the patient is also on multimodal antihypertensive treatment, such as a beta-blocker and/or a diuretic.
Aspirin therapy should be continued if the patient has a history of coronary artery disease, peripheral vascular disease, or cerebrovascular disease. However, this should be discussed with the surgeon and weighed against the risk of intraoperative bleeding versus the risk of thrombosis.
Similar to aspirin therapy, antiplatelet medication should be continued unless the risk of bleeding outweighs the risk of thrombosis. This should be discussed with the surgeon. If platelet therapy needs to be discontinued, then it should be stopped 5 to 7 days prior to surgery. Antiplatelet therapy should not be discontinued in patients who have received a bare metal stent within the last 4 weeks or a drug-eluting stent within 12 months of the surgery without consultation with the surgeon and the patient’s cardiologist.
Diuretics used for hypertensive therapy or for heart failure should be continued until the day of surgery. Diuretics being used for any other purpose should be held the day of surgery.
Warfarin should be discontinued 7 days prior to surgery.
Due to the fact that the procedure can induce bronchospasm, the patient should be instructed to take all pulmonary medications the day of surgery. Patients should bring their beta-agonist inhalers to the hospital so that they can take it prior to surgery.
Topical medications should be discontinued the day of surgery.
i. How to modify care for patients with known allergies –
During the preoperative history, the anesthesiologist should identify the patient’s allergies. If the patient is allergic to a specific narcotic, alternative narcotic choices should be made available for the procedure. Other medications that are identified as allergies should be avoided during the procedure and alternatives made available for the procedure.
j. Latex allergy- If the patient has a sensitivity to latex, such as a rash from gloves, underwear, etc, versus anaphylactic reaction, prepare the operating room with latex-free products.
Care should be taken to ensure that the anesthesia machine’s components, such as reservoir bag, NIBP cuff, ECG leads, etc, are latex free. In addition, intravenous tubing, including injection ports must be latex free.
Patients who have a history of anaphylactic reaction to latex should have all of their drugs drawn up fresh without going through the diaphragm of medication vials. Latex can be found in some diaphragms of medication bottles. As a result, the tops of these vials, including the diaphragms, should be removed before drawing up the medications.
Small amounts of latex can also be found in the stopper of some syringes. For medications that have been pre-filled by the pharmacy in these syringes, they should not be administered due to the risk of latex leaching out into the medication over time.
k. Does the patient have any antibiotic allergies- – Common antibiotic allergies and alternative antibiotics]
Patients with penicillin allergies have been reported to have a cross-reactivity to cephalosporin in 7-18% of cases. As a result, cephalosporins are often barred from patients with a history of penicillin allergies.
Assessment of the nature of the allergy, including the drug, onset, duration, and extent of the reaction, is required to determine the safety of starting cephalosporin therapy.
If there is concern about the safety of a particular antibiotic, alternative antibiotic treatment with a similar microbial susceptibility profile should be substituted.
l. Does the patient have a history of allergy to anesthesia?
During the preoperative history, the patient should be asked about a personal history and family history of allergy to anesthesia. Patients with a documented personal or family history of malignant hyperthermia should have a trigger-free anesthetic. The anesthesia machine needs to be flushed thoroughly with the reservoir bag, circuit, and soda lime changed prior to the initiation of the anesthetic.
If possible, inhalational anesthetic canisters should be removed from the anesthetic machine. All triggering agents, such as succinylcholine, should be avoided. A malignant hyperthermia card should be available and its protocol reviewed prior to the anesthesia. The anesthetic can be performed as a total intravenous general anesthetic without the use of triggering agents.
Allergy to muscle relaxants can prove to be challenging for this procedure. Direct laryngoscopy required for exposure to the vocal cords is highly stimulating. Due to the delicate nature of the surgery, immobilization of the vocal cords is required for the surgeon to perform the surgery. Allergy to muscle relaxants can be overcome with a deep anesthetic that may require a multimodal technique including inhalational anesthetic, narcotics, and intravenous hypnotics.
A history of local anesthetic allergy should not be of consequence during this procedure. Local anesthetics can be avoided as they are not integral to the surgery or the anesthetic.
5. What laboratory tests should be obtained and has everything been reviewed?
No laboratory tests need to be obtained specifically for this procedure. As stated previously, if the patient has active cardiac symptoms, stress tests and/or echocardiography may be necessary prior to the procedure.
Common laboratory normal values will be same for all procedures, with a difference by age and gender
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
Vocal cord polypectomy is usually performed using suspension microlaryngoscopy. This optimizes visualization of the vocal cords and the larynx, but it is very stimulating and most patients will not be able to tolerate it awake or with sedation only. Thus, vocal cord polypectomies are usually performed under general anesthesia with neuromuscular blockade. Surgical technique, patient comorbidities, and anesthesiologist skill level dictate whether an endotracheal tube, jet ventilation, or intermittent mask ventilation will be used.
Since the lesion is on the vocal cords, placing an endotracheal tube must be done carefully to avoid disrupting or damaging the vocal cord polyp or cyst. Further, patients with a history of sleep apnea or difficult airway may be challenging to intubate with direct laryngoscopy. In these patients, fiberoptic intubation or a videolaryngoscope, such as Glidescope®, should be considered. The videolaryngoscope may be superior because it allows “direct” visualization of the vocal cords during endotracheal tube placement and may decrease the potential for trauma to the lesion.
If an endotracheal tube is used, the smallest size that allows for adequate ventilation, while still providing satisfactory exposure for the surgery, should be placed. If jet ventilation is used, the catheter may be placed just above or below the vocal cords.
Jet ventilation should only be used when both the surgeon and anesthesiologist are comfortable with the technique. If intermittent apnea is selected, mask ventilation must be feasible. For this technique, the surgeon works during periods of apnea and, when the SaO2 reaches a level that is determined by the patient’s comorbidities, mask ventilation resumes.
Some surgeons prefer no airway instruments in the field while they are operating and the surgeon’s rigid laryngoscope can serve to ventilate the patient. Alternatively, the surgeon can intermittently intubate the patient with an endotracheal tube on the field. This allows the vocal cords to remain in the suspended position, causing the least amount of disruption to the surgeon’s view.
If a laser is going to be used for resection of the polyp, a laser-resistant tube should be used. In these cases, the inspired oxygen concentration should be less than 30% and nitrous oxide should be avoided.
For emergency vocal cord polypectomy, preparations for securing the airway, including those for an emergency tracheostomy, must be done prior to entering the operating room. An awake fiberoptic intubation may be required.
6. What is the author's preferred method of anesthesia technique and why?
Vocal cord polypectomy is a delicate surgery that requires good visualization of the anatomy. In order for the surgeon to work comfortably, the bed is usually turned 90-180 degrees. If a laser is to be utilized, a laser-resistant endotracheal tube is used and the cuff inflated with saline.
Ideally, the endotracheal tube should be placed under direct laryngoscopy to minimize the amount of trauma to the lesion and the vocal cords. The smallest sized endotracheal tube possible should be used to maintain adequate ventilation, while still allowing for appropriate visualization by the surgeon; usually a 5.5-6.0 mm endotracheal tube works well. If a laser is used during the procedure, the inspired oxygen concentration should be lowered to 30% or less to decrease the risk of airway fire.
Currently, there are no SCIP recommendations for antibiotic administration for vocal cord polypectomy. Administration of dexamethasone may be helpful intraoperatively to decrease airway edema.
Direct laryngoscopy, along with the suspension microlaryngoscopy, can cause increased heart rate and blood pressure, resulting in myocardial ischemia, especially in patients with coronary artery disease. Narcotics and increased levels of an inhalational anesthetic can help reduce the hypertension and tachycardia. Beta blockers and alpha antagonists may also be helpful.
Direct laryngoscopy can also exacerbate bronchospasm and beta agonists should be readily available to treat bronchospasm.
a. If the patient is intubated, are there any special criteria for extubation?
While we take great care to intubate these patients, care must also be taken during extubation. The cuff of the endotracheal tube must be completely emptied prior to extubation. Cuffs with retained air can cause damage to the vocal cords, as well as to the arytenoids. Deep extubation can be considered if the patient is easily maskable and is not at risk for aspiration.
b. Postoperative management
Postoperatively, the patient can go to the post anesthesia care unit (PACU) for recovery. The patient should be monitored for airway obstruction. Patients usually complain of a sore throat; however, minimal amounts of narcotics are required postoperatively. Complete voice rest is required after surgery. This is usually an outpatient procedure and patients go home without complications after a short recovery period in the PACU.
What's the Evidence?
Sataloff, RT, Hawkshaw, MJ, Divi, V, Heman-Ackah, YD. “Voice surgery”. Otolaryngol Clin North Am. vol. 40. 2007. pp. 1151-1184.
Sheinbein, DS, Loeb, RG. “Laser surgery and fire hazards in ear, nose, and throat surgeries”. Anesthesiol Clin. vol. 28. 2010. pp. 485-96.
Ahmed, F, Kinshuck, AJ, Harrison, M, O’Brien, D, Lancaster, J, Roland, NJ, Jackson, SR, Jones, TM. “Laser safety in head and neck cancer surgery”. Eur Arch Otorhinolaryngol. vol. 267. 2010. pp. 1779-84.
Johns, MM. “Update on the etiology, diagnosis, and treatment of vocal fold nodules, polyps, and cysts”. Curr Opin Otolaryngol Head Neck Surg. vol. 11. 2003. pp. 456-61.
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- What the Anesthesiologist Should Know before the Operative Procedure
- 1. What is the urgency of the surgery?
- What is the risk of delay in order to obtain additional preoperative information?
- 2. Preoperative evaluation
- 3. What are the implications of co-existing disease on perioperative care?
- a. Cardiovascular system
- b. Pulmonary
- c. Renal-GI
- d. Neurologic
- e. Endocrine
- f. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
- 4. What are the patient's medications and how should they be managed in the perioperative period?
- g. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
- h. What should be recommended with regard to continuation of medications taken chronically?
- i. How to modify care for patients with known allergies -
- j. Latex allergy- If the patient has a sensitivity to latex, such as a rash from gloves, underwear, etc, versus anaphylactic reaction, prepare the operating room with latex-free products.
- k. Does the patient have any antibiotic allergies- - Common antibiotic allergies and alternative antibiotics]
- l. Does the patient have a history of allergy to anesthesia?
- 5. What laboratory tests should be obtained and has everything been reviewed?
- Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
- 6. What is the author's preferred method of anesthesia technique and why?
- a. If the patient is intubated, are there any special criteria for extubation?
- b. Postoperative management