Glossectomy - Revision history

Chris.Rishel at 07:49, 5 April 2022

2022-04-05T07:49:41Z

← Older revision		Revision as of 00:49, 5 April 2022
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	{{Infobox surgical procedure		{{Infobox surgical procedure
	\| anesthesia_type = General		\| anesthesia_type = General
	\| airway = Nasal ETT~~, Oral ETT, consider~~ awake		\| airway = Nasal or oral ETT
			Consider awake intubation
	\| lines_access = PIV		\| lines_access = PIV
	\| monitors = Standard, 5-lead ECG		\| monitors = Standard
	\| considerations_preoperative = Extent of tumor ~~and airway~~ history ~~including history of~~ head and neck radiation		5-lead ECG
			\| considerations_preoperative = Extent of tumor
			Airway history (head and neck radiation)
	\| considerations_intraoperative = Adequate muscle relaxation		\| considerations_intraoperative = Adequate muscle relaxation
	Electrocautery and risk of airway fire		Electrocautery and risk of airway fire

Chris.Rishel: Text replacement - "|Respiratory" to "|Pulmonary"

2022-02-22T05:46:17Z

Text replacement - "|Respiratory" to "|Pulmonary"

← Older revision		Revision as of 22:46, 21 February 2022
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	\|Consider [[Coronary artery disease\|CAD]]/vascular disease/HTN if smoking history		\|Consider [[Coronary artery disease\|CAD]]/vascular disease/HTN if smoking history
	\|-		\|-
	\|~~Respiratory~~		\|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]]		\|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]]
	\|-		\|-

Chris.Rishel at 21:12, 21 February 2022

2022-02-21T21:12:21Z

← Older revision		Revision as of 14:12, 21 February 2022
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	[[Category:Surgical procedures]]		[[Category:Surgical procedures]]
			<references />
			[[Category:Otolaryngology]]
			[[Category:Pharyngeal surgery]]

Helen.Heymann at 19:28, 18 February 2022

2022-02-18T19:28:20Z

← Older revision		Revision as of 12:28, 18 February 2022
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	\|-		\|-
	\|Cardiovascular		\|Cardiovascular
	\|Consider [[Coronary artery disease\|CAD]]/vascular disease if smoking history		\|Consider [[Coronary artery disease\|CAD]]/vascular disease/HTN if smoking history
	\|-		\|-
	\|Respiratory		\|Respiratory

Helen.Heymann at 15:24, 18 February 2022

2022-02-18T15:24:55Z

← Older revision		Revision as of 08:24, 18 February 2022
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	* Bleeding		* Bleeding
	** Manipulation of mass		** Manipulation of mass
	** Lingual artery/~~vein, deep lingual vein~~		** Lingual artery/veins
	** Consider external jugular/carotid if neck dissection		** Consider external jugular/carotid if neck dissection
	* Salivary fistula		* Salivary fistula

Helen.Heymann at 15:23, 18 February 2022

2022-02-18T15:23:06Z

← Older revision		Revision as of 08:23, 18 February 2022
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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
	\|~~Mouth~~ opening, presence of trismus, tongue fixation / mass obstruction of the airway. Consider pulmonary pathology related to smoking history. Consider OSA and possible related [[pulmonary hypertension]]		\|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
	\|-
	~~\|Renal~~
	\|
	\|-
	~~\|Endocrine~~
	\|
	\|-		\|-
	\|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
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	* 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~~/PCA~~ opioid analgesics		* 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. --> ===
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	* 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" />
	* ~~Skin graft~~ failure		* 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
	\|-
	~~\|Unique considerations~~
	\|
	\|
	\|-		\|-
	\|Surgical time		\|Surgical time

Helen.Heymann at 01:00, 18 February 2022

2022-02-18T01:00:44Z

← Older revision		Revision as of 18:00, 17 February 2022
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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.<ref name=":0">{{Citation\|last=Bigcas\|first=Jo-Lawrence M.\|title=Glossectomy\|date=2022\|url=http://www.ncbi.nlm.nih.gov/books/NBK560636/\|work=StatPearls\|place=Treasure Island (FL)\|publisher=StatPearls Publishing\|pmid=32809471\|access-date=2022-02-17\|last2=Okuyemi\|first2=Oluwafunmilola T.}}</ref>		'''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.<ref name=":0">{{Citation\|last=Bigcas\|first=Jo-Lawrence M.\|title=Glossectomy\|date=2022\|url=http://www.ncbi.nlm.nih.gov/books/NBK560636/\|work=StatPearls\|place=Treasure Island (FL)\|publisher=StatPearls Publishing\|pmid=32809471\|access-date=2022-02-17\|last2=Okuyemi\|first2=Oluwafunmilola T.}}</ref>

	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.<ref name=":0" />		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.<ref name=":0" />

	== Preoperative management ==		== Preoperative management ==

Chris.Rishel at 00:50, 18 February 2022

2022-02-18T00:50:08Z

Show changes

Helen.Heymann at 00:11, 18 February 2022

2022-02-18T00:11:41Z

← Older revision		Revision as of 17:11, 17 February 2022
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	\| lines_access = PIV		\| lines_access = PIV
	\| monitors = Standard, 5-lead ECG		\| monitors = Standard, 5-lead ECG
	\| considerations_preoperative = ~~History~~ of head and neck radiation~~, extent of tumor and airway history~~		\| considerations_preoperative = Extent of tumor and airway history including history of head and neck radiation
	\| considerations_intraoperative = Adequate muscle relaxation/PONV prophylaxis, electrocautery and risk of airway fire, tracheostomy may be indicated		\| considerations_intraoperative = Adequate muscle relaxation/PONV prophylaxis, electrocautery and risk of airway fire, tracheostomy may be indicated
	\| considerations_postoperative = Assess degree of airway edema, smooth extubation		\| considerations_postoperative = Assess degree of airway edema, smooth extubation
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	\|-		\|-
	\|Respiratory		\|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		\|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		\|Gastrointestinal
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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		* Supplemental equipment for a possible difficult airway including glidescope, fiberoptic, 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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	* Consider preoperative endoscopic or laryngoscopic airway exam to assess tumor extension<ref name=":2">{{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 preoperative endoscopic or laryngoscopic airway exam to assess tumor extension<ref name=":2">{{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 pre-op acetaminophen 500-1000 mg PO		* 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		* 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. --> ===~~

	== Intraoperative management ==		== Intraoperative management ==
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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 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>		* Standard premedication, pre-op administration of antisialogogue (glycopyrrolate) may improve operating conditions - check with surgeon<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>
	* 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		* Consider awake fiberoptic if large tumor at the tongue base
			* If nasal/airway landmarks effaced, consider awake tracheostomy

	=== 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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	* Supine, arms tucked		* Supine, arms tucked
	* Arm positioning may differ if radial free flap		* Arm positioning may differ if radial free flap
	* If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries		* If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries<ref name=":1" />
	* Table often 180°		* Table often 180°

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	* Prophylactic steroids for airway edema		* Prophylactic steroids for airway edema
	* PONV prophylaxis with dexamethasone and ondansetron		* PONV prophylaxis with dexamethasone and ondansetron
	* Maintain FiO2 <0.3 ~~if lasers are used~~ to prevent airway fire		* 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<ref name=":1" />		* Of note, surgical manipulation at the base of the tongue can cause vagally mediated ↓ HR, ↓ BP<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>

	=== 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		* 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)		* Smooth extubation important if skin graft used for closure (graft hematomas are the primary cause of skin graft failure)<ref>{{Cite journal\|last=Llanos\|first=Sergio\|last2=Danilla\|first2=Stefan\|last3=Barraza\|first3=Cristina\|last4=Armijo\|first4=Eugenia\|last5=Pi??eros\|first5=Jose L.\|last6=Quintas\|first6=Maria\|last7=Searle\|first7=Susana\|last8=Calderon\|first8=Wilfredo\|date=2006-11\|title=Effectiveness of Negative Pressure Closure in the Integration of Split Thickness Skin Grafts: A Randomized, Double-Masked, Controlled Trial\|url=http://journals.lww.com/00000658-200611000-00014\|journal=Annals of Surgery\|language=en\|volume=244\|issue=5\|pages=700–705\|doi=10.1097/01.sla.0000217745.56657.e5\|issn=0003-4932\|pmc=PMC1856589\|pmid=17060762}}</ref>
	* ~~Extubation~~ after recovery of protective airway reflexes		* Extubate 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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	=== 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. --> ===

	* Airway obstruction second to airway edema		* Airway obstruction second to airway edema - may require treatment with humidified oxygen or nebulized bronchodilators
	* Bleeding		* Bleeding
	* Infection		* Infection
	* Aspiration		* Aspiration
	* ~~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~~>		* Specific to glossectomy: dysarthria, dysphagia, altered tongue sensation (lingual nerve trauma or neuropathic/phantom sensation), salivary fistula, osteonecrosis if mandibulotomy <ref name=":0" />

	== 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). --> ==

Helen.Heymann at 23:47, 17 February 2022

2022-02-17T23:47:58Z

← Older revision		Revision as of 16:47, 17 February 2022
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	\| 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, extent of tumor and airway history
	\| considerations_intraoperative = Adequate muscle relaxation, electrocautery and risk of airway fire, tracheostomy may be indicated		\| considerations_intraoperative = Adequate muscle relaxation/PONV prophylaxis, electrocautery and risk of airway fire, tracheostomy may be indicated
	\| considerations_postoperative = Assess degree of airway edema, smooth extubation		\| considerations_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.<ref name=":0">{{Citation\|last=Bigcas\|first=Jo-Lawrence M.\|title=Glossectomy\|date=2022\|url=http://www.ncbi.nlm.nih.gov/books/NBK560636/\|work=StatPearls\|place=Treasure Island (FL)\|publisher=StatPearls Publishing\|pmid=32809471\|access-date=2022-02-17\|last2=Okuyemi\|first2=Oluwafunmilola T.}}</ref>		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.<ref name=":0">{{Citation\|last=Bigcas\|first=Jo-Lawrence M.\|title=Glossectomy\|date=2022\|url=http://www.ncbi.nlm.nih.gov/books/NBK560636/\|work=StatPearls\|place=Treasure Island (FL)\|publisher=StatPearls Publishing\|pmid=32809471\|access-date=2022-02-17\|last2=Okuyemi\|first2=Oluwafunmilola T.}}</ref>

	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.<ref name=":0" />		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.<ref name=":0" />

	== Preoperative management ==		== Preoperative management ==
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	\|-		\|-
	\|Other		\|Other
	\|		\|Consider history of alcohol abuse in head and neck cancers
	\|}		\|}

	=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===		=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===

	* CT/MRI		* Head CT/MRI

	=== 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		* Supplemental equipment for a possible difficult airway including glidescope, fiberoptic, equipment for surgical airway
	* If oral intubation, reinforced ETT and bite block recommended		* 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

	=== 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 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 preoperative endoscopic or laryngoscopic airway exam to assess tumor extension<ref name=":2">{{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 pre-op acetaminophen 500-1000 mg PO
	* Consider aprepitant 40-80 mg for patients with history of severe PONV		* Consider aprepitant 40-80 mg for patients with history of severe PONV

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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>		* Standard premedication, preop administration of antisialogogue (glycopyrrolate) may improve operating conditions - check with surgeon<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>
	* 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		* Consider awake fiberoptic if large tumor at the tongue base
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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. --> ===

	* TIVA with propofol/remifentanil or propofol/sufentanil useful for smooth extubation (opioid blunting tracheal response)		* TIVA with propofol/remifentanil or propofol/sufentanil useful for smooth extubation (opioid blunting tracheal response)<ref name=":2" />
	* Complete muscle relaxation essential		* Complete muscle relaxation essential
	* Maintaining lower MAP not mandatory but can decrease bleeding		* Maintaining lower MAP not mandatory but can decrease bleeding
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	* PONV prophylaxis with dexamethasone and ondansetron		* PONV prophylaxis with dexamethasone and ondansetron
	* Maintain FiO2 <0.3 if lasers are used to prevent airway fire		* 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		* Of note, surgical manipulation at the base of the tongue can cause vagally mediated ↓ HR, ↓ BP<ref name=":1" />

	=== 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. --> ===
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	* Infection		* Infection
	* Aspiration		* Aspiration
			* 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>

	== 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). --> ==