Airway Management After Radiation Therapy for Nasopharyngeal Carcinoma

 

Background: Radiation therapy (RT) remains the mainstay of management for nasopharyngeal carcinoma (NPC). Airway status is of particular importance in NPC patients who often require complex airway management in the context of salvage surgeries or procedures related to treatment sequelae. The objective of this study is to characterize the incidence and perioperative management of difficult airway (DA) in patients who have undergone primary radiation treatment(s) for NPC.

Methods: A retrospective chart review was performed for adult patients with a history of NPC status post RT and subsequent evaluation at the authors’ institution between 1/1/2000 and 12/31/2018. Data on patient demographics, diagnoses, radiation therapy, post-RT procedures, and anesthesia records were extracted. In cases of multiple post-RT procedures, up to 4 procedure events per patient were recorded. Primary analysis was performed between those who underwent post-RT procedures (procedure group) and those who did not (control group). A secondary analysis was performed for the procedure group, with procedure events stratified by those flagged as a “difficult airway” based on preoperative anesthesia assessment (DA group) and those not (non-DA group).

Results: A total of 150 patients were included in the analysis. Of 150 patients (71.3%), 107 underwent post-RT procedures requiring airway management (Table 1). There was no significant difference between age (p = 0.65) and sex between the procedure and control groups. The control group was noted to have a greater proportion of Stage IVb cases (20.9 vs. 6.5%). A total of 183 procedure events were identified and analyzed (Table 2). 75/183 (40.9%) were included in the DA group. There was a significantly greater time lapse between RT completion and time of procedure in the DA group (13.8 vs. 7.5 years, p < 0.0001). Compared with those in the non-DA group, patients in the DA group had significantly higher Mallampati scores and higher proportion of short thyromental distance, limited neck range of motion, and trismus (p < 0.0001 for all). All but 1 non-DA case was managed by anesthesia, whereas 4/75 (5.3%) of DA cases were managed by otolaryngologists. DAs required a higher number of attempts to secure the airway (p = 0.03). 2 DAs and 1 non-DA resulted in unplanned surgical airways. Oropharyngeal or nasopharyngeal bleeding was the most common perioperative complication and occurred in 4 (5.3%) and 1 (0.9%) of DA and non-DA cases, respectively.

Conclusion: This study is the first to characterize airway management in post-RT NPC patients. Post-RT, many NPC patients present with challenging airways requiring specialized equipment and personnel. Further analysis is needed (including multivariate regression, to be completed in this study) to identify predictors of airway difficulty. It is critical to identify these patients in the preoperative setting to prevent intraoperative or delayed airway-related complications.

Publication History

Article published online:
01 February 2023

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