1. Introduction

    Radical neck dissection is required when cancerous tumors have invaded the musculature and other structures of the head and neck. These tumors are often friable and bleed readily. These patients are frequently heavy drinkers and smokers who have bronchitis, pulmonary emphysema, or cardiovascular disease. If the tumor interferes with eating, then weight loss, malnutrition, anemia, dehydration, and electrolyte imbalance can be significant. Patients who have had radiation treatments of the neck and jaw before surgical intervention will have soft tissues that are less mobile, making intubation more difficult. Many of these patients are older. The number of complications in patients age 65 years and older is nearly double that of younger patients. Consultation with a surgeon as to the nature, extent, and location of the tumor; therapy administered (radiation or chemotherapy); CT results; history and physical examination; and so on remains important in determining the appropriate techniques for airway management.

    Head and neck reconstruction is an integral part of surgical removal of head and neck tumors. Traditional methods of reconstruction include regional pedicle flaps with microvascular reconstruction. These flaps include pectoralis major myocutaneous flap; trapezius flap; and local rotational flaps, such as forehead flap. Additionally, small bowel may be harvested to reconstruct the oropharynx and esophagus. The anesthesia team plays an important role in maximizing the overall success rate of a free flap and microvascular flow of the flap. The anesthesia provider must communicate with the surgeon regarding the planned donor site, which limits the available sites to place lines necessary for monitoring and venous access. Although the choice of monitoring is largely dependent on the general condition of the patient, the placement of a CVP line, a Foley catheter, and an arterial line (beat-to-beat and arterial blood gas trends) is suggested, particularly if deliberate hypotension during anesthesia is used. A pulmonary artery catheter may be useful if a history of cardiac problems is present. The internal jugular approach should be avoided because of proximity to the surgical site. Sites commonly used for CVP and pulmonary catheter placement when the internal jugular is not accessible are the subclavian and femoral veins, respectively.