The anesthetic considerations for the patient undergoing total laryngectomy.

Patients with laryngeal tumors may present with a deviated trachea or with a reduced tracheal lumen size due to preoperative radiation therapy. A short-acting induction agent and muscle relaxant is indicated in the event of difficult intubation and a smaller than expected endotracheal tube may be necessary should the tracheal lumen be reduced. A reversible muscle relaxant is suggested in order to provide spontaneous breathing intraoperatively at the surgeon's request. A total laryngectomy may be performed for multiple laryngeal papillomatosis or for laryngeal car-cinoma. Laryngeal papillomas are frequently found in children, and reoccurrence following surgical removal is common. The reoccurrence may be severe enough to require laryngectomy in an effort to alleviate respiratory obstruction. Carcinoma of the larynx occurs ten times more frequently in males than in females. It generally appears in the fifth, sixth, and seventh decade of life. The most common cell type noted is squamous and the degree ranges from in situ to undifferentiated carcinoma. Laryngeal cancer is highly curable if detected early. The overall cure rate of laryngopharyngeal carcinoma is 57%. When the carcinoma is localized to the larynx, the five year survival rate is 76%, and when the tumor is limited to the mid-third of the true vocal cord, cure rates as high as 96% have been reported. 4 However, if regional nodes are involved the five year survival rate can be as low as 29%. 4 Guidelines for appropriate treatment have been established by tle American Joint Committee for Cancer Staging and the International Union Against Cancer. Frequently, the extent of the disease requires a partial to total removal of the larynx. A thorough understanding of the anatomy of the larynx and pathophysiology of the disease, as well as of the surgical technique intended, is essential to develop a plan of care which will provide a physiologic anesthetic for these patients. Anatomical review The larynx opens posteriorly into the pharynx and inferiorly into the trachea. It extends vertically to the level of the fourth through sixth cervical vertebrae. This position may be somewhat higher in the female and in the child. Until puberty, the larynx of the male differs little in size from that of the female. During puberty, the male cartilages enlarge considerably-the thyroid cartilage becomes prominent in the midline while the rima glottidis doubles. 1 The entire larynx is covered with mucous membrane; the anterior surface and the upper half of the …