From Scan to Strategy: Study evaluates Impact of 3D CT and Virtual Endoscopy on Airway Management in Head and Neck Cancer

Recent study evaluates the impact of advanced airway assessment techniques-specifically 3D computed tomography (3D CT) reconstruction and virtual endoscopy-on airway management in adult patients undergoing head and neck cancer surgery under general anaesthesia.

Traditional clinical airway assessments, including physical examination and routine imaging, often miss significant airway abnormalities, leading to unanticipated difficulties during intubation.

Methodology: A prospective, randomized design involved 60 patients allocated into two groups: -Group A: Conventional airway assessment based on clinical examination and routine imaging. -Group B: Conventional assessment plus additional 3D CT reconstruction and virtual endoscopy of the airway. Preoperative CT scans, performed within 4 weeks of surgery, were reconstructed into 3D models and analyzed using a tailored reporting format developed after literature review and consultation with radiologists and airway experts. For cases with luminal obstructions, virtual endoscopy videos highlighted intraluminal features. The anaesthesiologists received these findings prior to surgery, and any modifications to their airway management plan were documented. The primary outcome measured was the total time required for successful airway management (from device passage to capnography confirmation). Secondary outcomes included attempts, maneuvers, alternative techniques, complications, and failed intubations.

Key Findings:- Airway management time: Similar between groups, with median differences of zero (P=0.752). - \*\*Use of manoeuvres:\*\* Optimal external laryngeal manipulation (OELM) was needed more frequently in the conventional group (P=0.007), suggesting better initial airway assessment with 3D CT reduced the need for adjunct maneuvers. - \*\*Device and technique modifications:\*\* Shown in the results, notably a significant change in endotracheal tube size (P<0.001), often leading to better fitting and fewer intraoperative difficulties.

- \*\*Nasal intubation:\*\* The CT findings helped select the more patent nostril (moderate agreement, kappa=0.545). - \*\*Intubation difficulty:\*\* No significant difference in attempts or complications; both groups had comparable success rates and complication profiles.

- \*\*Subjective assessment:\*\* Anaesthesiologists rated the use of 3D CT as beneficial (majority giving moderate to high Likert scale scores).

\*\*Limitations:\*\* - Predominantly supraglottic lesions, with limited cases of luminal obstruction, restricted extensive virtual endoscopy evaluation. Operator familiarity with 3D CT parameters is limited, underscoring the need for further standardization and validation.

\*\*Conclusions:\*\* While the addition of 3D CT reconstruction and virtual endoscopy did not significantly reduce overall airway management time, it provided valuable airway insights—particularly for nasal intubation and luminal abnormalities—that could influence clinical decision-making. These imaging modalities can complement conventional assessment tools in managing challenging airways in head and neck cancer patients, aiding in preoperative planning and technique selection. Further research with larger cohorts and standardization of CT parameter interpretation is necessary to fully establish their clinical utility.

Key Points

- Additional 3D CT reconstruction and virtual endoscopy provided detailed insights into airway anatomy, particularly aiding in the identification of luminal obstructions and optimal nostril selection, thereby improving preoperative planning in head and neck cancer patients.

- The use of advanced imaging techniques reduced the need for adjunct maneuvers such as optimal external laryngeal manipulation (OELM), indicating an improvement in initial airway assessment accuracy with 3D CT and virtual endoscopy.

- Despite these benefits, the overall time required for airway management was similar between groups, suggesting that advanced imaging did not significantly expedite the intubation process in this study.

- Modifications in airway management strategies—especially changing endotracheal tube size—were significantly more common in the group with advanced imaging, which contributed to potentially smoother intraoperative airway management.

- Both groups showed comparable success rates, number of attempts, and complication profiles during intubation, indicating that advanced imaging primarily influenced planning rather than immediate procedural success.

- Subjective assessments by anesthesiologists favored the use of 3D CT and virtual endoscopy, with clinicians perceiving these modalities as beneficial for understanding airway anatomy and guiding decision-making, though limitations such as small sample size and lack of standardized normative data were noted.

Reference –

Ganjoo S, Dhamija E, Garg R, Bhatnagar S, Mishra S, Bharati SJ, et al. To assess the impact of advanced airway imaging (3D CT reconstruction and virtual endoscopy of airway) on airway management in adult patients undergoing head and neck cancer surgeries under general anaesthesia: Randomised controlled study (3D ARC Study: 3D Airway Reconstruction for Cancer airway management). Indian J Anaesth 2025;69:899-908.