Difference between revisions of "Glossectomy"
From WikiAnesthesia
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{{Infobox surgical procedure | {{Infobox surgical procedure | ||
| anesthesia_type = General | | anesthesia_type = General | ||
| airway = Nasal ETT, Oral ETT | | airway = Nasal ETT, Oral ETT, consider awake | ||
| lines_access = PIV | | lines_access = PIV | ||
| monitors = Standard, 5-lead ECG | | monitors = Standard, 5-lead ECG | ||
| considerations_preoperative = History of head and neck radiation, airway history | | considerations_preoperative = History of head and neck radiation, airway history | ||
| considerations_intraoperative = Adequate muscle relaxation, electrocautery and risk of airway fire, tracheostomy may be indicated | | considerations_intraoperative = Adequate muscle relaxation, electrocautery and risk of airway fire, tracheostomy may be indicated | ||
| considerations_postoperative = | | considerations_postoperative = Assess degree of airway edema, smooth extubation | ||
}} | }} | ||
| Line 28: | Line 28: | ||
|- | |- | ||
|Respiratory | |Respiratory | ||
|Mouth opening, mass obstruction of the airway, presence of trismus | |Mouth opening, tongue fixation / mass obstruction of the airway, presence of trismus. Consider pulmonary pathology related to smoking history. Consider OSA and possible related pHTN | ||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
|Assess for dysphagia | |Assess for dysphagia/GERD | ||
|- | |- | ||
|Hematologic | |Hematologic | ||
| Line 51: | Line 51: | ||
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | === Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | ||
* Supplemental equipment for a possible difficult airway including glidescope, fiberoptic, equipment for surgical airway | |||
* If oral intubation, reinforced ETT and bite block recommended | |||
* Assistance should be immediately available during induction | |||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | === Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | ||
* Consider preoperative | * Consider preoperative endoscopic or laryngoscopic airway exam to assess tumor extension<ref>{{Cite book|last=Nekhendzy|first=V|url=http://worldcat.org/oclc/983210379|title=Airway management in head and neck surgery. In: Hagberg's Benumof Airway Management, 4th edition|last2=Biro|first2=P|publisher=Elsevier Saunders|year=2018|isbn=978-0-323-42881-1|location=Philadelphia|pages=668-91|oclc=983210379}}</ref> | ||
* Consider preop acetaminophen 500-1000 mg PO | |||
* Consider aprepitant 40-80 mg for patients with history of severe PONV | |||
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | === Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ||
| Line 67: | Line 73: | ||
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | === Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ||
* Standard premedication, preop administration of antisialogogue (glycopyrrolate) may improve operating conditions - check with surgeon<ref>{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Lippincott Williams & Wilkins (LWW)|year=2019|isbn=978-1-49-637125-6|location=|pages=233-235}}</ref> | |||
* Nasal intubation may or may not be required depending on tumor location (for example, side versus base of tongue) and surgeon's preference | * Nasal intubation may or may not be required depending on tumor location (for example, side versus base of tongue) and surgeon's preference | ||
* Consider awake fiberoptic if large tumor at the tongue base | |||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ||
| Line 78: | Line 86: | ||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ||
* | * TIVA with propofol/remifentanil or propofol/sufentanil useful for smooth extubation (opioid blunting tracheal response) | ||
* Complete muscle relaxation essential | |||
* Maintaining lower MAP not mandatory but can decrease bleeding | |||
* Prophylactic steroids for airway edema | * Prophylactic steroids for airway edema | ||
* PONV prophylaxis with dexamethasone and ondansetron | |||
* Maintain FiO2 <0.3 if lasers are used to prevent airway fire | |||
* Of note, surgical manipulation at the base of the tongue can cause vagally mediated ↓ HR, ↓ BP | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
* Assess degree of upper airway obstruction prior to extubation - may be impossible to reintubate if obstruction occurs | |||
* Smooth extubation important if skin graft used for closure (graft hematomas are the primary cause of skin graft failure) | |||
* Extubation after recovery of protective airway reflexes | |||
* If extubated, may require treatment with humidified oxygen or nebulized bronchodilators | |||
== Postoperative management == | == Postoperative management == | ||
| Line 87: | Line 105: | ||
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | === Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ||
* Inpatient admission depending on size/location, free flap, tracheostomy | |||
* Encourage early nutrition, foley removal, mobilization | * Encourage early nutrition, foley removal, mobilization | ||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | === Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ||
* Multimodal including | * Intraoperative infiltration with local anesthetic | ||
* Multimodal including non-opioid and bolus/PCA opioid analgesics | |||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | === Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ||
| Line 105: | Line 125: | ||
|+ | |+ | ||
! | ! | ||
! | !Partial | ||
! | !Subtotal/Total Resection | ||
|- | |- | ||
|Unique considerations | |Unique considerations | ||
| Line 113: | Line 133: | ||
|- | |- | ||
|Position | |Position | ||
| | |Supine | ||
| | |<-- | ||
|- | |- | ||
|Surgical time | |Surgical time | ||
| | |1-3 hr | ||
| | |3-8 hr | ||
|- | |- | ||
|EBL | |EBL | ||
| | |50-150 mL | ||
| | |100-300 mL | ||
|- | |- | ||
|Postoperative disposition | |Postoperative disposition | ||
| | |Inpatient depending on degree of resection / neck dissection / flap | ||
| | |<-- May require prolonged intubation or tracheostomy care | ||
|- | |- | ||
|Pain management | |Pain management | ||
| | |Multimodal | ||
| | |<-- | ||
|- | |- | ||
|Potential complications | |Potential complications | ||
| | |Bleeding, infection, aspiration | ||
| | |<-- | ||
|} | |} | ||
Revision as of 15:35, 17 February 2022
Glossectomy
| Anesthesia type |
General |
|---|---|
| Airway |
Nasal ETT, Oral ETT, consider awake |
| Lines and access |
PIV |
| Monitors |
Standard, 5-lead ECG |
| Primary anesthetic considerations | |
| Preoperative |
History of head and neck radiation, airway history |
| Intraoperative |
Adequate muscle relaxation, electrocautery and risk of airway fire, tracheostomy may be indicated |
| Postoperative |
Assess degree of airway edema, smooth extubation |
| Article quality | |
| Editor rating | |
| User likes | 1 |
Glossectomy refers to surgical removal of part or all the tongue. It is primarily performed for excision of malignant lesions in addition to benign neoplasms of the tongue, obstructive sleep apnea, and macroglossia. Excisional or incisional biopsies of tongue lesions of undetermined etiology are also performed.[1]
There are several approaches to performing a glossectomy, most commonly transorally (through the mouth) for smaller and shallower tumors. Larger tumors or those with significant depth may require resection of the lower lip and mandible ("lip-split mandibulotomy"), or opening the sublingual or submental compartments for improved visualization of the inferior tongue ("transcervical pull-through"). Neck dissection and reconstruction can be performed for all glossectomy procedures.[1]
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic | |
| Cardiovascular | Consider CAD if smoking history |
| Respiratory | Mouth opening, tongue fixation / mass obstruction of the airway, presence of trismus. Consider pulmonary pathology related to smoking history. Consider OSA and possible related pHTN |
| Gastrointestinal | Assess for dysphagia/GERD |
| Hematologic | |
| Renal | |
| Endocrine | |
| Other |
Labs and studies
- CT/MRI
Operating room setup
- Supplemental equipment for a possible difficult airway including glidescope, fiberoptic, equipment for surgical airway
- If oral intubation, reinforced ETT and bite block recommended
- Assistance should be immediately available during induction
Patient preparation and premedication
- Consider preoperative endoscopic or laryngoscopic airway exam to assess tumor extension[2]
- Consider preop acetaminophen 500-1000 mg PO
- Consider aprepitant 40-80 mg for patients with history of severe PONV
Regional and neuraxial techniques
Intraoperative management
Monitoring and access
- Standard monitors, PIV
- Mouth gags per surgeon
Induction and airway management
- Standard premedication, preop administration of antisialogogue (glycopyrrolate) may improve operating conditions - check with surgeon[3]
- Nasal intubation may or may not be required depending on tumor location (for example, side versus base of tongue) and surgeon's preference
- Consider awake fiberoptic if large tumor at the tongue base
Positioning
- Supine, arms tucked
- Arm positioning may differ if radial free flap
- If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries
- Table often 180°
Maintenance and surgical considerations
- TIVA with propofol/remifentanil or propofol/sufentanil useful for smooth extubation (opioid blunting tracheal response)
- Complete muscle relaxation essential
- Maintaining lower MAP not mandatory but can decrease bleeding
- Prophylactic steroids for airway edema
- PONV prophylaxis with dexamethasone and ondansetron
- Maintain FiO2 <0.3 if lasers are used to prevent airway fire
- Of note, surgical manipulation at the base of the tongue can cause vagally mediated ↓ HR, ↓ BP
Emergence
- Assess degree of upper airway obstruction prior to extubation - may be impossible to reintubate if obstruction occurs
- Smooth extubation important if skin graft used for closure (graft hematomas are the primary cause of skin graft failure)
- Extubation after recovery of protective airway reflexes
- If extubated, may require treatment with humidified oxygen or nebulized bronchodilators
Postoperative management
Disposition
- Inpatient admission depending on size/location, free flap, tracheostomy
- Encourage early nutrition, foley removal, mobilization
Pain management
- Intraoperative infiltration with local anesthetic
- Multimodal including non-opioid and bolus/PCA opioid analgesics
Potential complications
- Airway obstruction second to airway edema
- Bleeding
- Infection
- Aspiration
Procedure variants
| Partial | Subtotal/Total Resection | |
|---|---|---|
| Unique considerations | ||
| Position | Supine | <-- |
| Surgical time | 1-3 hr | 3-8 hr |
| EBL | 50-150 mL | 100-300 mL |
| Postoperative disposition | Inpatient depending on degree of resection / neck dissection / flap | <-- May require prolonged intubation or tracheostomy care |
| Pain management | Multimodal | <-- |
| Potential complications | Bleeding, infection, aspiration | <-- |
References
- ↑ 1.0 1.1 Bigcas, Jo-Lawrence M.; Okuyemi, Oluwafunmilola T. (2022), "Glossectomy", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 32809471, retrieved 2022-02-17
- ↑ Nekhendzy, V; Biro, P (2018). Airway management in head and neck surgery. In: Hagberg's Benumof Airway Management, 4th edition. Philadelphia: Elsevier Saunders. pp. 668–91. ISBN 978-0-323-42881-1. OCLC 983210379.
- ↑ Jaffe, Richard (2019). Anesthesiologist's Manual of Surgical Procedures. Lippincott Williams & Wilkins (LWW). pp. 233–235. ISBN 978-1-49-637125-6.
Top contributors: Helen Heymann, Olivia Sutton and Chris Rishel