What are the anesthetic considerations for a patient with a large right submandibular gland impinging on the oral cavity undergoing tube gastrostomy?

Anesthetic Considerations for Large Submandibular Mass During Gastrostomy Placement

This patient requires a secured airway via awake fiberoptic intubation or video laryngoscopy with immediate availability of emergency surgical airway equipment, as the 6.7cm submandibular mass poses critical risk for airway obstruction and difficult mask ventilation.

Primary Airway Management Concerns

Anticipated Difficult Airway

• The large right submandibular gland (6.7x6.8x5.3 cm) impinging leftward creates significant anatomic distortion that predicts difficult mask ventilation, difficult laryngoscopy, and potential complete airway obstruction upon induction 1
• Submandibular masses of this size can cause acute airway compromise during sedation or general anesthesia due to loss of pharyngeal muscle tone and posterior displacement of the tongue 2
• Awake fiberoptic intubation is the safest approach, maintaining spontaneous ventilation until the airway is definitively secured 1

Alternative Airway Strategies

• If awake intubation is not feasible, video laryngoscopy with careful titration of sedation while maintaining spontaneous ventilation is an acceptable alternative 1
• Have immediate access to emergency cricothyrotomy equipment and personnel capable of performing emergency surgical airway 1
• Avoid supraglottic airways (LMA) as they can cause acute submandibular gland swelling and further airway compromise 2

Aspiration Risk Management

Positioning and Monitoring

• Position patient at minimum 30° head elevation during the procedure to minimize aspiration risk, which occurs in 0.3-1.0% of gastrostomy cases 3
• Maintain this positioning for 30 minutes post-procedure 3
• Risk factors for intraprocedural aspiration include supine position, sedation, and neurologic impairment 3

Gastric Decompression

• Place nasogastric tube for gastric decompression prior to induction if patient has delayed gastric emptying or gastroparesis 3
• Consider prokinetic agents (metoclopramide or erythromycin) if gastric residuals are anticipated 3

Procedural Approach Selection

Transabdominal vs Transoral Technique

• Strongly favor image-guided transabdominal gastrostomy placement over endoscopic transoral approach in this patient 3
• Transabdominal technique avoids passage through the oropharynx, which is already compromised by the submandibular mass 3
• This approach reduces infection risk (30% vs <10%) and avoids additional airway manipulation 3

Coagulation Management

Preoperative Optimization

• Gastrostomy is a high-risk bleeding procedure requiring INR <1.5 and platelet count >50,000/μL 3
• Withhold clopidogrel for 5 days; continue aspirin 3
• Withhold therapeutic low molecular weight heparin for one dose 3

Contraindications Assessment

Absolute Contraindications to Verify Absence

• Mechanical GI obstruction (unless for decompression), active peritonitis, uncorrectable coagulopathy, or bowel ischemia 3
• Colonic interposition between abdominal wall and stomach (requires surgical approach if present) 3

Relative Contraindications

• Recent GI bleeding from peptic ulcer with visible vessel or esophageal varices requires 72-hour delay 3
• Hemodynamic instability, significant ascites, or respiratory compromise require optimization before proceeding 3

Antibiotic Prophylaxis

• Administer first-generation cephalosporin or similar agent covering cutaneous organisms prior to incision 3
• This reduces peristomal infection rate from 30% to <10% 3

Postoperative Airway Monitoring

Extubation Considerations

• Delay extubation until patient is fully awake with intact airway reflexes and ability to protect airway 1
• Monitor for at least 6-8 hours post-procedure for bleeding or airway swelling, as submandibular surgery typically shows plateau in drainage by this timepoint 4
• Have reintubation equipment immediately available at bedside 1

Common Pitfalls to Avoid

• Never induce general anesthesia without a definitive airway plan in patients with large neck masses 1
• Avoid assuming mask ventilation will be possible—this mass size predicts difficult or impossible mask ventilation 2
• Do not use supine positioning during the procedure, as this increases aspiration risk from 0.3% to 15% 3
• Avoid transoral endoscopic approach which requires additional airway manipulation in already compromised anatomy 3