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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
}}
}}


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|-
|-
|Respiratory
|Respiratory
|Mouth opening, mass obstruction of the airway, presence of trismus, tongue fixation, consider pulmonary pathology related to smoking history
|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
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=== 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 flexible laryngoscopy to assess tumor extension
* 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. --> ===
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=== 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. --> ===
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=== 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. --> ===


* Maintain FiO2 <0.3 if lasers are used
* 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 ==
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=== 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 nonopioid and bolus/PCA opioid analgesics with peripheral local anesthetic
* 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. --> ===
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|+
|+
!
!
!Variant 1
!Partial
!Variant 2
!Subtotal/Total Resection
|-
|-
|Unique considerations
|Unique considerations
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|-
|-
|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 16:35, 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
Comprehensive
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. ↑ 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
  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. ↑ 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

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