Introduction

Chondronecrosis is a known complication of radiation, and symptoms may present years following treatment.1,4,5 It is the most common cause of chondronecrosis. Endotracheal intubation has, on occasion, been associated with chondronecrosis and is thought to be secondary to excessive pressure of the tube or cuff on the cartilage itself, with the cricoid ring most commonly affected.1,2,6 The use of the laryngeal mask airway (LMA) should in theory prevent this complication, and is a reasonable choice for anesthesia in patients who have undergone prior radiotherapy for laryngeal cancer. LMA is generally effective and well-tolerated, with a low side-affect profile. We report the first case of chondronecrosis secondary to use of an LMA, which was successfully managed with hyperbaric oxygen therapy and reconstructive surgery.

Chondronecrosis of the larynx following general anesthesia via laryngeal mask airway

Daniel M. Beswick, MD; Jennifer Bergeron, MD; Edward J. Damrose, MD, FACS Department of Otolaryngology-Head and Neck Surgery

Stanford University Medical Center, Stanford, California.

Abstract

Purpose: To present the first report of laryngeal chondronecrosis following use of the laryngeal mask airway. Design and Method: Case study. Description: A 69 year old male underwent total knee replacement via general anesthesia using the laryngeal mask airway. Five days following surgery the patient noted progressive hoarseness and odynophagia. The patient developed aspiration and barium swallow demonstrated a tracheo-esophageal fistula. Soon thereafter the patient developed airway obstruction secondary to bilateral vocal cord paralysis and underwent tracheostomy with direct laryngoscopy and esophagoscopy. Complete necrosis of the posterior cricoid plate with a 1.2 cm hole was found. The patient was successfully treated with hyperbaric oxygen therapy and intravenous antibiotics, and repair of the defect with a postcricoid mucosal advancement flap. Vocal fold motion returned and the patient was decannulated. Conclusions: This is the first reported case of chondronecrosis following use of the laryngeal mask airway. Anesthesiologists need to be alert for the potential for this type of complication, particularly in patients who have undergone prior radiation therapy.

General anesthesia via laryngeal mask airway is a generally effective technique with a low risk of complications. When used in patients with a history of radiation therapy to the larynx and pharynx, its use should be viewed with caution, with special attention paid to correct sizing and placement so as not to induce pressure injury to surrounding structures. Any patient with progressing odynophagia, dysphagia, hoarseness or dyspnea following LMA or ETT particularly in the setting of prior radiation therapy should be promptly evaluated for possible chondronecrosis and appropriate treatment instituted immediately.

Conclusions

Discussion

Case Report

A 69 year old male underwent routine total knee replacement using general anesthesia via LMA. Of note, he had undergone radiation therapy for a T1aN0M0 squamous cell carcinoma of the larynx five years previously, receiving a total of 66 Gy. Over the ensuing three days, the patient noted progressive odynophagia, treated initially with steroids and antibiotics. The patient improved with medical therapy, but worsened following completion. He subsequently developed symptoms of aspiration, with an esophagram demonstrating a fistula (Fig 1). He was managed medically but developed progressive dyspnea and required tracheostomy for bilateral vocal fold immobility. At the time of tracheostomy, he underwent direct laryngoscopy demonstrating necrosis of the posterior cricoid plate (Fig 2-3) with a fistula into the subglottic larynx. He underwent hyperbaric oxygen therapy and intravenous antibiotics. His vocal fold mobility improved and he was decannulated. Post treatment demonstrated a persistent though small defect in the postcricoid larynx (Fig 4), which was closed endoscopically with a laterally based postcricoid mucosal advancement flap (Fig 5-6). Postoperative swallowing function improved and the patient ’ s gastrostomy tube was subsequently removed. Though considered as potential treatment, total laryngectomy proved unnecessary.

Fig 4: Persistent fistula following hyperbaric oxygen therapy. Endotracheal tube is visible in airway when viewed from the pharynx.

Fig 6: Endoscopic view of plugged fistula.

Fig 2: Necrosis of cricoid plate with fistula.

Laryngeal chondronecrosis is a known but rare complication of radiation therapy1 and endotracheal intubation.2,3 Both these interventions can decrease blood supply to the laryngotracheal mucosa and cause local ischemia. Supraglottic airway devices such as LMAs are frequently used in airway management. The case discussed herein describes the development of chondronecrosis after LMA placement in a patient who previously underwent external beam radiation. To our knowledge, no prior reports of chondronecrosis from an LMA have been reported.

LMAs are generally considered very safe devices for airway management. The most serious reported complication of LMA use is aspiration. This complication is exceedingly rare, estimated at 0.02%,7 and is within the range of 0.01% to 0.06% of aspiration for anesthetized patients.8 When compared to endotracheal intubation, a systematic review showed that LMAs resulted in a lower incidence of hoarseness, laryngospasm during emergence, coughing, and sore throat.9

Prompt recognition of laryngeal chondronecrosis is important to prevent further sequelae. Our single report demonstrates that LMA-induced chondronecrosis can be managed with antibiotics, endoscopic repair and hyperbaric oxygen, and does not necessarily require total laryngectomy or tracheostomy.

Successful placement of the LMA is integral to its safe function. Capillary perfusion pressure of the laryngotracheal mucosa is 20-25 mm Hg.10 Manufacturer guidelines for the LMA ClassicTM (Teleflex Medical, Dublin, Ireland) state that this device forms a seal of approximately 20 mm H20 around the larynx. Users are directed to “NEVER OVERINFLATE THE CUFF” and to maintain a cuff pressure of “ideally about 60 mm H2O.”11 The case presented here suggests that use of an LMA can in fact cause laryngeal chondronecrosis in an at-risk patient.

Fig 1: Esophagram demonstrating fistula into airway.

Fig 3: Necrotic cricoid plate following antibiotic therapy. This was subsequently debrided.

References

1. Keene M, Harwood AR, Bryce DP, van Nostrand AW. Histopathological study of radionecrosis in laryngeal carcinoma. Laryngoscope. 1982 Feb;92(2):173-80.

2. Ali AA, Shweihat YR, Bartter T. Cricoid chondronecrosis: a complication of endotracheal intubation. J Ark Med Soc. 2012 Feb;108(9):192-4.

3. Wiel E, Vilette B, Solanet C, Darras JA, Scherpereel P. Chondronecrosis of the cricoid cartilage after intubation. Two case reports. Eur J Anaesthesiol. 1997 Jul;14(4):461-3.

4. Cukurova I, Cetinkaya EA. Radionecrosis of the larynx: Case report and review of the literature. Acta Otorhinol Italica 2010; 30: 205-208.

5. Chandler JR. Radiation fibrosis and necrosis of the larynx. Ann Otol Rhinol Laryngol 1979;88:509-14.

6. Gehanno P, Leowski S, Lallemant Y, Crepin A. [Chondronecrosis of the cricoid after prolonged intubation (author's transl)]. Ann Otolaryngol Chir Cervicofac. 1980 Sep;97(9): 711-24. French.

7. Keller C, Brimacombe J, Bittersohl J, Lirk P, von Goedecke A. Aspiration and the laryngeal mask airway: three cases and a review of the literature. Br J Anaesth 2004;93:579 – 82

8. Asai T. Editorial II: Who is at increased risk of pulmonary aspiration? Br J Anaesth 2004;93:497–500.

9. Yu S, Berine OR. Laryngeal Mask Airways Have Lower Risk of Airway Complications Compared with Endotracheal Intubation: A Systematic Review. J Oral Maxillofac Surg. 2010 Oct;86(10):2359-76.

10. Nordin U, Lindholm CE, Wolgast M. Blood flow in the rabbit tracheal mucosa under normal conditions and the influence of tracheal intubation. Acta Anaesthesiol Scand 1977 21(2):81-94.

11. LMATM, The Larygneal Mask Company Limited. Instructions for Use – LMA Classic, LMA Flexible, LMA Flexible Single Use and LMA Unique. Teleflex Medical. Dublin Road, Westmeath, Ireland. 866246 6990. 1-3. www.lmaco.com. Accessed 11 April 2014.

Chandler Classification of Laryngeal Radionecrosis a

A Adapted from Cukurova I, Cetinkaya EA. Radionecrosis of the larynx: Case report and review of the literature. Acta Otorhinol Italica 2010; 30: 205-208.

Fig 5: Fistula closed with left laterally based postcricoid mucosal advancement flap.

Symptoms Signs Treatment

Grade 1 Slight hoarseness, slight

dryness Slight edema,

telangiectasia Symptomatic care,

humidification

Grade 2 Moderate hoarseness,

moderate dryness

Grade 3

Severe hoarseness with

dyspnea, moderate

odynophagia and

dysphagia

Severe impairment of vocal

cord mobility or fixation of

one cord, marked edema,

skin changes

Steroids, antibiotics

Tracheotomy +/- laryngectomy

Grade 4 Respiratory distress,

severe odynophagia,

weight loss, dehydration

Fistula, fixation of skin to

larynx, airway obstruction,

fever Tracheotomy +/- laryngectomy