Difference between revisions of "Glossectomy"
From WikiAnesthesia
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|- | |- | ||
|Neurologic | |Neurologic | ||
| | |Consider stroke risk if smoking history, tongue direction if prior surgeries or hypoglossal nerve involvement | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
|Consider [[Coronary artery disease|CAD]] if smoking history | |Consider [[Coronary artery disease|CAD]]/vascular disease if smoking history | ||
|- | |- | ||
|Respiratory | |Respiratory | ||
| | |Assess compliance of airway including neck mobility, mouth opening, presence of trismus, tongue fixation / mass obstruction of the airway. Check patency of each nare. Consider pulmonary pathology related to smoking history. Consider OSA and possible related [[pulmonary hypertension]] | ||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
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|- | |- | ||
|Hematologic | |Hematologic | ||
| | |Consider DVT risk if smoking/cancer history | ||
|- | |- | ||
|Other | |Other | ||
|Consider history of alcohol abuse in head and neck cancers | |Consider history of alcohol abuse in head and neck cancers, assess nutritional status | ||
|} | |} | ||
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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 video laryngoscope, fiberoptic, equipment for surgical airway<ref name=":2" /> | * Supplemental equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula, 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 | ||
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* Standard monitors, PIV | * Standard monitors, PIV | ||
* Mouth gags per surgeon | * Mouth gags/lip retractors per surgeon | ||
=== 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. --> === | ||
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* Standard premedication | * Standard premedication | ||
* Administration of antisialogogue (glycopyrrolate) may improve operating conditions<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> | * Administration of antisialogogue (glycopyrrolate) may improve operating conditions<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> | ||
* Decreased compliance due to neck radiation is the most significant predictor of difficult mask ventilation<ref>{{Cite journal|last=Kheterpal|first=Sachin|last2=Martin|first2=Lizabeth|last3=Shanks|first3=Amy M.|last4=Tremper|first4=Kevin K.|date=2009-04-01|title=Prediction and Outcomes of Impossible Mask Ventilation: A Review of 50,000 Anesthetics|url=https://doi.org/10.1097/ALN.0b013e31819b5b87|journal=Anesthesiology|volume=110|issue=4|pages=891–897|doi=10.1097/ALN.0b013e31819b5b87|issn=0003-3022}}</ref> | |||
** Consider high flow nasal cannula for pre-oxygenation | |||
* Nasal intubation may be required depending on tumor location (e.g. side versus base of tongue) and surgeon preference | * Nasal intubation may be required depending on tumor location (e.g. side versus base of tongue) and surgeon preference | ||
* Consider awake fiberoptic intubation if large tumor at the tongue base | * Consider awake fiberoptic intubation if large tumor at the tongue base | ||
| Line 92: | Line 88: | ||
* TIVA with propofol and remifentanil or sufentanil | * TIVA with propofol and remifentanil or sufentanil | ||
** Opioid infusion useful for smooth extubation<ref name=":2" /> | ** Opioid infusion useful for smooth extubation<ref name=":2" /> | ||
* Complete muscle relaxation essential | * Complete muscle relaxation essential, may use rocuronium | ||
* Maintaining lower MAP not mandatory but can decrease bleeding | * 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 | * PONV prophylaxis with dexamethasone and ondansetron | ||
* Maintain FiO2 <30% to prevent airway fire from electrocautery use | * Maintain FiO2 <30% to prevent airway fire from electrocautery use | ||
* Goal euvolemia | |||
** Patients may be volume depleted prior to surgery and require fluid boluses | |||
* Surgical manipulation at the base of the tongue can cause vagally mediated bradycardia and hypotension<ref name=":1" /> | * Surgical manipulation at the base of the tongue can cause vagally mediated bradycardia and hypotension<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> | * 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> | ||
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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 | * Inpatient admission depending on size/location of resection, free flap, tracheostomy | ||
* Encourage early nutrition, foley removal, mobilization | * Encourage early nutrition, foley removal, mobilization | ||
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* Intraoperative infiltration with local anesthetic | * Intraoperative infiltration with local anesthetic | ||
* Multimodal including non-opioid and bolus | * Multimodal including non-opioid and bolus opioid analgesics | ||
* Consider opioid PCA if subtotal/total glossectomy | |||
=== 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 124: | Line 123: | ||
* Airway obstruction due to airway edema | * Airway obstruction due to airway edema | ||
** May require treatment with humidified oxygen or nebulized bronchodilators | ** May require treatment with humidified oxygen or nebulized bronchodilators | ||
* Altered tongue sensation (lingual nerve trauma or neuropathic/phantom sensation) | * Altered tongue sensation (lingual nerve trauma or neuropathic/phantom sensation)<ref name=":0" /> | ||
* Aspiration | * Aspiration | ||
* Dysarthria | * Dysarthria, from loss of musculature or post-operative changes such as tongue tethering from scar tissue<ref name=":0" /> | ||
* Dysphagia | * Dysphagia | ||
* Bleeding | * Bleeding | ||
** Manipulation of mass | |||
** Lingual artery/vein, deep lingual vein | |||
** Consider external jugular/carotid if neck dissection | |||
* Salivary fistula | * Salivary fistula | ||
* Osteonecrosis if mandibulotomy<ref name=":0" /> | * Osteonecrosis if mandibulotomy<ref name=":0" /> | ||
* | * Graft failure | ||
== 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). --> == | ||
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!Partial | !Partial | ||
!Subtotal/Total Resection | !Subtotal/Total Resection | ||
|- | |- | ||
|Surgical time | |Surgical time | ||
Revision as of 08:23, 18 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 Electrocautery and risk of airway fire Tracheostomy may be indicated |
| Postoperative |
Assess degree of airway edema PONV prophylaxis Smooth extubation |
| Article quality | |
| Editor rating | |
| User likes | 1 |
Glossectomy refers to the 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 flap reconstruction may be performed for glossectomy procedures.[1]
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic | Consider stroke risk if smoking history, tongue direction if prior surgeries or hypoglossal nerve involvement |
| Cardiovascular | Consider CAD/vascular disease if smoking history |
| Respiratory | Assess compliance of airway including neck mobility, mouth opening, presence of trismus, tongue fixation / mass obstruction of the airway. Check patency of each nare. Consider pulmonary pathology related to smoking history. Consider OSA and possible related pulmonary hypertension |
| Gastrointestinal | Assess for dysphagia/GERD |
| Hematologic | Consider DVT risk if smoking/cancer history |
| Other | Consider history of alcohol abuse in head and neck cancers, assess nutritional status |
Labs and studies
- Head CT/MRI
Operating room setup
- Supplemental equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula, 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 endoscopic or laryngoscopic airway exam to assess tumor extension[2]
- Consider 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/lip retractors per surgeon
Induction and airway management
- Standard premedication
- Administration of antisialogogue (glycopyrrolate) may improve operating conditions[3]
- Decreased compliance due to neck radiation is the most significant predictor of difficult mask ventilation[4]
- Consider high flow nasal cannula for pre-oxygenation
- Nasal intubation may be required depending on tumor location (e.g. side versus base of tongue) and surgeon preference
- Consider awake fiberoptic intubation 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 and remifentanil or sufentanil
- Opioid infusion useful for smooth extubation[2]
- Complete muscle relaxation essential, may use rocuronium
- Maintaining lower MAP not mandatory but can decrease bleeding
- Prophylactic steroids for airway edema
- PONV prophylaxis with dexamethasone and ondansetron
- Maintain FiO2 <30% to prevent airway fire from electrocautery use
- Goal euvolemia
- Patients may be volume depleted prior to surgery and require fluid boluses
- Surgical manipulation at the base of the tongue can cause vagally mediated bradycardia and hypotension[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 [5]
Emergence
- Assess degree of upper airway obstruction prior to extubation
- Reintubation may be impossible if obstruction occurs
- Smooth extubation important if skin graft used for closure
- Graft hematomas are the primary cause of skin graft failure[6]
- Extubate after recovery of protective airway reflexes
Postoperative management
Disposition
- Inpatient admission depending on size/location of resection, free flap, tracheostomy
- Encourage early nutrition, foley removal, mobilization
Pain management
- Intraoperative infiltration with local anesthetic
- Multimodal including non-opioid and bolus opioid analgesics
- Consider opioid PCA if subtotal/total glossectomy
Potential complications
- Airway obstruction due to airway edema
- May require treatment with humidified oxygen or nebulized bronchodilators
- Altered tongue sensation (lingual nerve trauma or neuropathic/phantom sensation)[1]
- Aspiration
- Dysarthria, from loss of musculature or post-operative changes such as tongue tethering from scar tissue[1]
- Dysphagia
- Bleeding
- Manipulation of mass
- Lingual artery/vein, deep lingual vein
- Consider external jugular/carotid if neck dissection
- Salivary fistula
- Osteonecrosis if mandibulotomy[1]
- Graft failure
Procedure variants
| Partial | Subtotal/Total Resection | |
|---|---|---|
| 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 |
References
- ↑ 1.0 1.1 1.2 1.3 1.4 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.
- ↑ Kheterpal, Sachin; Martin, Lizabeth; Shanks, Amy M.; Tremper, Kevin K. (2009-04-01). "Prediction and Outcomes of Impossible Mask Ventilation: A Review of 50,000 Anesthetics". Anesthesiology. 110 (4): 891–897. doi:10.1097/ALN.0b013e31819b5b87. ISSN 0003-3022. no-break space character in
|first4=at position 6 (help); no-break space character in|first3=at position 4 (help) - ↑ 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)
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