HOCM, difficult airway, cancer recurrence

73yo male with a local recurrence of SCC around the cheek/infra-auricular area.

Background

  • Facial SCC – WLE, neck dissection and radiotx March.
  • DASI 6.6 METS
  • PD – minor speech and swallowing changes
  • Polycythaemia rubra vera – hydroxyurea and venesections q3/12
  • Iron deficiency anaemia
  • NHL – Chemotx, treated

Issues

  • HOCM
    • Known since 2016, mod on TTE
    • Cardiologist review due to 6/12 history of worsening SOB
    • SOB and angina with slight inclines
    • TTE Aug ’21 showed severe LVOT obstruction, gradient 86mmHg
    • Cardiologist commenced beta-blocker
    • Ongoing review – Holter to look for ventricular tachydysrhythmias, ? will need defib, ? add disopyramide. 
    • Family to be referred for genetic testing
  • Timing of procedure
    • Ongoing cardiac workup and modification
    • Surg team keen to avoid delays where possible, due to previous local metastasis
  • Anaesthetic technique – surg reg suggests could be done under LA
  • Airway
    • Moderately difficult BMV and grade 2 laryngoscopy in March
    • Patient notes reduced MO since radiotx

Discussion

  • Anaesthetic technique
    • LA spread may be unreliable due to previous surgery
    • Concerns about sedation with likely difficult airway if conversion to GA required mid-case
    • Low physiologic stress procedure. Stress not appreciably reduced by loco-regional technique rather than GA.
    • HD stability desirable with HOCM
  • Timing
    • Thought that if Holter reassuring and asymptomatic from recent beta-blocker addition, then appropriate to proceed without delays to cancer surgery.
    • Likely that the degree LVOT obstruction is unchanged since previous anaesthetic in March, which was well tolerated.

Plan

  • Discuss Holter result with cardiologist – further treatment adjustment needed? disease severity likely stable since March.
  • Notification of procedural anaesthetist – airway assessment and plan on DOS. Patient aware that AFOI may be required.