Difference between revisions of "Glossectomy"
From WikiAnesthesia
| Line 4: | Line 4: | ||
| lines_access = PIV | | lines_access = PIV | ||
| monitors = Standard, 5-lead ECG | | monitors = Standard, 5-lead ECG | ||
| considerations_preoperative = | | considerations_preoperative = Extent of tumor and airway history including history of head and neck radiation | ||
| considerations_intraoperative = Adequate muscle relaxation/PONV prophylaxis, electrocautery and risk of airway fire, tracheostomy may be indicated | | considerations_intraoperative = Adequate muscle relaxation/PONV prophylaxis, electrocautery and risk of airway fire, tracheostomy may be indicated | ||
| considerations_postoperative = Assess degree of airway edema, smooth extubation | | considerations_postoperative = Assess degree of airway edema, smooth extubation | ||
| Line 28: | Line 28: | ||
|- | |- | ||
|Respiratory | |Respiratory | ||
|Mouth opening, tongue fixation / mass obstruction of the airway | |Mouth opening, presence of trismus, tongue fixation / mass obstruction of the airway. Consider pulmonary pathology related to smoking history. Consider OSA and possible related pHTN | ||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
| Line 52: | Line 52: | ||
=== 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 | * Supplemental equipment for a possible difficult airway including glidescope, fiberoptic, equipment for surgical airway<ref name=":2" /> | ||
* If oral intubation, reinforced ETT and bite block recommended<ref name=":1" /> | * If oral intubation, reinforced ETT and bite block recommended<ref name=":1" /> | ||
* Assistance should be immediately available during induction | * Assistance should be immediately available during induction | ||
| Line 59: | Line 59: | ||
* Consider preoperative endoscopic or laryngoscopic airway exam to assess tumor extension<ref name=":2">{{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 preoperative endoscopic or laryngoscopic airway exam to assess tumor extension<ref name=":2">{{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 pre-op acetaminophen 500-1000 mg PO | * Consider pre-op acetaminophen 500-1000 mg PO as part of multimodal regimen | ||
* Consider aprepitant 40-80 mg for patients with history of severe PONV | * Consider aprepitant 40-80 mg for patients with history of severe PONV | ||
== Intraoperative management == | == Intraoperative management == | ||
| Line 73: | Line 71: | ||
=== 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, | * Standard premedication, pre-op administration of antisialogogue (glycopyrrolate) may improve operating conditions - check with surgeon<ref name=":1">{{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 | * Consider awake fiberoptic if large tumor at the tongue base | ||
* If nasal/airway landmarks effaced, consider awake tracheostomy | |||
=== 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 81: | Line 80: | ||
* Supine, arms tucked | * Supine, arms tucked | ||
* Arm positioning may differ if radial free flap | * Arm positioning may differ if radial free flap | ||
* If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries | * If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries<ref name=":1" /> | ||
* Table often 180° | * Table often 180° | ||
| Line 91: | Line 90: | ||
* Prophylactic steroids for airway edema | * Prophylactic steroids for airway edema | ||
* PONV prophylaxis with dexamethasone and ondansetron | * PONV prophylaxis with dexamethasone and ondansetron | ||
* Maintain FiO2 <0.3 | * Maintain FiO2 <0.3 to prevent airway fire as electrocautery used | ||
* Of note, surgical manipulation at the base of the tongue can cause vagally mediated ↓ HR, ↓ BP<ref name=":1" /> | * Of note, surgical manipulation at the base of the tongue can cause vagally mediated ↓ HR, ↓ BP<ref name=":1" /> | ||
* If neck dissection, consider risk of bleeding (external jugular/carotid artery), dysrhythmias if compression of the carotid sinus, venous air embolism if open veins <ref>{{Cite book|last=Feldman|first=MA|title=Anesthesia for eye, ear, nose, and throat surgery. In: Miller RD, ed. Miller's Anesthesia, 7th edition|last2=Patel|first2=A|publisher=Elsevier|year=2010|isbn=|location=Philadelphia|pages=2357-88}}</ref> | |||
=== 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 | * 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) | * Smooth extubation important if skin graft used for closure (graft hematomas are the primary cause of skin graft failure)<ref>{{Cite journal|last=Llanos|first=Sergio|last2=Danilla|first2=Stefan|last3=Barraza|first3=Cristina|last4=Armijo|first4=Eugenia|last5=Pi??eros|first5=Jose L.|last6=Quintas|first6=Maria|last7=Searle|first7=Susana|last8=Calderon|first8=Wilfredo|date=2006-11|title=Effectiveness of Negative Pressure Closure in the Integration of Split Thickness Skin Grafts: A Randomized, Double-Masked, Controlled Trial|url=http://journals.lww.com/00000658-200611000-00014|journal=Annals of Surgery|language=en|volume=244|issue=5|pages=700–705|doi=10.1097/01.sla.0000217745.56657.e5|issn=0003-4932|pmc=PMC1856589|pmid=17060762}}</ref> | ||
* | * Extubate after recovery of protective airway reflexes | ||
== Postoperative management == | == Postoperative management == | ||
| Line 115: | Line 114: | ||
=== 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. --> === | ||
* Airway obstruction second to airway edema | * Airway obstruction second to airway edema - may require treatment with humidified oxygen or nebulized bronchodilators | ||
* Bleeding | * Bleeding | ||
* Infection | * Infection | ||
* Aspiration | * Aspiration | ||
* | * Specific to glossectomy: dysarthria, dysphagia, altered tongue sensation (lingual nerve trauma or neuropathic/phantom sensation), salivary fistula, osteonecrosis if mandibulotomy <ref name=":0" /> | ||
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | == Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | ||
Revision as of 16:11, 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 |
Extent of tumor and airway history including history of head and neck radiation |
| Intraoperative |
Adequate muscle relaxation/PONV prophylaxis, 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 may be performed for glossectomy procedures.[1]
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic | |
| Cardiovascular | Consider CAD if smoking history |
| Respiratory | Mouth opening, presence of trismus, tongue fixation / mass obstruction of the airway. Consider pulmonary pathology related to smoking history. Consider OSA and possible related pHTN |
| Gastrointestinal | Assess for dysphagia/GERD |
| Hematologic | |
| Renal | |
| Endocrine | |
| Other | Consider history of alcohol abuse in head and neck cancers |
Labs and studies
- Head CT/MRI
Operating room setup
- Supplemental equipment for a possible difficult airway including glidescope, fiberoptic, equipment for surgical airway[2]
- If oral intubation, reinforced ETT and bite block recommended[3]
- Assistance should be immediately available during induction
Patient preparation and premedication
- Consider preoperative endoscopic or laryngoscopic airway exam to assess tumor extension[2]
- Consider pre-op acetaminophen 500-1000 mg PO as part of multimodal regimen
- Consider aprepitant 40-80 mg for patients with history of severe PONV
Intraoperative management
Monitoring and access
- Standard monitors, PIV
- Mouth gags per surgeon
Induction and airway management
- Standard premedication, pre-op 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
- If nasal/airway landmarks effaced, consider awake tracheostomy
Positioning
- Supine, arms tucked
- Arm positioning may differ if radial free flap
- If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries[3]
- Table often 180°
Maintenance and surgical considerations
- TIVA with propofol/remifentanil or propofol/sufentanil useful for smooth extubation (opioid blunting tracheal response)[2]
- 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 to prevent airway fire as electrocautery used
- Of note, surgical manipulation at the base of the tongue can cause vagally mediated ↓ HR, ↓ BP[3]
- If neck dissection, consider risk of bleeding (external jugular/carotid artery), dysrhythmias if compression of the carotid sinus, venous air embolism if open veins [4]
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)[5]
- Extubate after recovery of protective airway reflexes
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 - may require treatment with humidified oxygen or nebulized bronchodilators
- Bleeding
- Infection
- Aspiration
- Specific to glossectomy: dysarthria, dysphagia, altered tongue sensation (lingual nerve trauma or neuropathic/phantom sensation), salivary fistula, osteonecrosis if mandibulotomy [1]
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 1.2 Bigcas, Jo-Lawrence M.; Okuyemi, Oluwafunmilola T. (2022), "Glossectomy", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 32809471, retrieved 2022-02-17
- ↑ 2.0 2.1 2.2 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.
- ↑ 3.0 3.1 3.2 3.3 Jaffe, Richard (2019). Anesthesiologist's Manual of Surgical Procedures. Lippincott Williams & Wilkins (LWW). pp. 233–235. ISBN 978-1-49-637125-6.
- ↑ Feldman, MA; Patel, A (2010). Anesthesia for eye, ear, nose, and throat surgery. In: Miller RD, ed. Miller's Anesthesia, 7th edition. Philadelphia: Elsevier. pp. 2357–88.
- ↑ Llanos, Sergio; Danilla, Stefan; Barraza, Cristina; Armijo, Eugenia; Pi??eros, Jose L.; Quintas, Maria; Searle, Susana; Calderon, Wilfredo (2006-11). "Effectiveness of Negative Pressure Closure in the Integration of Split Thickness Skin Grafts: A Randomized, Double-Masked, Controlled Trial". Annals of Surgery. 244 (5): 700–705. doi:10.1097/01.sla.0000217745.56657.e5. ISSN 0003-4932. PMC 1856589. PMID 17060762. Check date values in:
|date=(help)CS1 maint: PMC format (link)
Top contributors: Helen Heymann, Olivia Sutton and Chris Rishel