Glossectomy

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	Comprehensive
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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.

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.

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
• 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
• 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
• 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
• 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 to prevent airway fire as electrocautery used
• Of note, surgical manipulation at the base of the tongue can cause vagally mediated ↓ HR, ↓ BP
• If neck dissection, consider risk of bleeding (external jugular/carotid artery), dysrhythmias if compression of the carotid sinus, venous air embolism if open veins

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)
• 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

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	<--