P065: POST FREE FLAP AIRWAY CONSIDERATIONS
Gianfranco Molfetto, DO1; Benjamin Houseman, MD1; Jonathan Bishop, MSIV2; 1Memorial Healthcare System; 2Virginia College of Osteopathic Medicine
Introduction and Case Report: This is the case of a 57 year old male with a T4b N0 M0 adenoid cystic carcinoma of the left parotid gland. He presented with a left parotid mass that slowly grew over 2 years. MRI of the neck shows a large tumor centered in let parotid gland, with evidence of local invasion into surrounding soft tissues and into the foramen ovale with mild degree of intracranial involvement of dura at level of foramen ovale. Perineural spread of tumor was also seen along left facial nerve in left facial nerve canal. Biopsy of left parotid mass shows adenoid cystic carcinoma. Patient underwent resection of his left parotid mass with left radical parotidectomy, segmental mandibulectomy, lateral temporal bone resection, middle fossa craniotomy, and left neck dissection and free flap reconstruction. Primary tumor was 6.5cm in size, tumor invading skin, external ear, masseter, temporalis muscle, medial and lateral pterygoid muscles, facial nerve, and mandibular nerve at trigeminal ganglion with diffuse multiple positive margins. Patient later underwent adjuvant radiotherapy with concurrent weekly cisplatin chemotherapy. He tolerated therapy well. He later underwent a PET/CT scan and was found to have a hypermetabolic small right thyroid nodule. A biopsy was completed which revealed papillary thyroid carcinoma.
The patient presented to our service for a total thyroidectomy. He was intubated successfully with an 8.0 endotracheal tube using video laryngoscopy.
The patient is now doing well post-operatively. Final pathology revealed a margin negative resection of the multifocal papillary thyroid carcinoma in bilateral thyroid lobes.
Discussion: There was concern that the patient’s history of free flap reconstruction would cause a distortion in their airway anatomy. It was important to take into consideration external vs internal airway abnormalities when approaching this case. We undertook appropriate precautions such as having a second provider at bedside, having a video laryngoscope, and difficult airway supplies. We will review the airway abnormalities and considerations that one should have when approaching a patient like this.