Glossectomy

Glossectomy

Anesthesia type	General
Airway	Nasal or oral ETT Consider awake intubation
Lines and access	PIV
Monitors	Standard 5-lead ECG
Primary anesthetic considerations
Preoperative	Extent of tumor Airway history (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
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Editor rating	Comprehensive
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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.

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.

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/HTN if smoking history
Pulmonary	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
• If oral intubation, reinforced ETT and bite block recommended
• Assistance should be immediately available during induction

Patient preparation and premedication

• Consider endoscopic or laryngoscopic airway exam to assess tumor extension
• 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
• Decreased compliance due to neck radiation is the most significant predictor of difficult mask ventilation
  • 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
• Table often 180°

Maintenance and surgical considerations

• TIVA with propofol and remifentanil or sufentanil
  • Opioid infusion useful for smooth extubation
• 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
• 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
  • 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
• 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)
• Aspiration
• Dysarthria, from loss of musculature or post-operative changes such as tongue tethering from scar tissue
• Dysphagia
• Bleeding
  • Manipulation of mass
  • Lingual artery/veins
  • Consider external jugular/carotid if neck dissection
• Salivary fistula
• Osteonecrosis if mandibulotomy
• 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