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

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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.[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.