A Reminder for a Very Rare Entity: Massive Tongue Swelling after Posterior Fossa Surgery

Abstract

Macroglossia is a rare complication following neurosurgical procedures with very few cases reported so far. It has been attributed to the sitting position and venous flow congestion. We illustrate a case of macroglossia, which occurred following surgery in the prone position. Its etiology remains speculative, but a neurogenic explanation seems most plausible.

Macroglossia in neurosurgery

“…Hassani et al [11] A reminder for a very rare entity: Massive tongue swelling after posterior fossa surgery Iwuchukwu et al [13] Macroglossia associated with brainstem injury Jakobson et al [32] Life-threatening macroglossia after trauma Kawaguchi et al [17] Pharyngeal packs can cause massive swelling of the tongue after neurosurgical procedures Koizumi et al [19] An operation in the park bench position complicated by massive tongue swelling Kuhnert et al [18] Postoperative macroglossia: Report of a case with rapid resolution after extubation of the trachea Krnacik et al [6] Severe angioedema causing airway obstruction after anterior cervical surgery Lam et al [5] Macroglossia: Compartment syndrome of the tongue?…”

“…In these patients, the tongue swelling failed to resolve and pressure from the endotracheal tube was thought to be a contributing factor. [1,4,5,[8][9][10][11][12][13] In addition to airway obstruction, other complications reported included pain associated with the macroglossia, [1,14,15] difficulty with speech and swallowing [12,[14][15][16] protrusion of the tongue leading to chronic drying and fissuring with superimposed infection, [12] necrosis, [5,7,14,15,17] ulceration [7,[18][19][20] and haematomas of the tongue. [15] In one case, mechanical dental compression worsened the macroglossia and resulted in a laceration.…”

“…In general, patients were placed in the upright position [2,14] to improve venous drainage. The use of medications included oral steroids (dexamethasone, [1,4,9,11,13,18,[23][24][25] hydrocortisone, [23,26] methylprednisolone [10,16,17] and triamcinolone, unspecified [6,7,14,19] ), and topical and oral analgesics. [1] However, steroid treatment was reported to be ineffective in some cases.…”

“…[1] However, steroid treatment was reported to be ineffective in some cases. [9][10][11] Antibiotics and anti-fungal treatments were used when concomitant infection was suspected. [14] Additional medications that were used included: sodium succinate, [10] ranitidine, [10] aerosols (ipratropium bromide, albuterol sulphate), [10] tranexamic acid, [10] promethazine, [10] cetirizine, [10] Objects placed in the mouth may interfere with venous and lymphatic drainage of the tongue and/or arterial inflow leading to ischaemia (see Figure 3 A, B).…”

11 Principles of Anesthesia in Skull Base Surgery

“…• Prolonged prone positioning and excessive fluid administration can sometimes be associated with venous congestion and facial edema, but more rarely with swelling of the tongue, soft palate, pharynx, and arytenoid. [56][57][58] After a prolonged procedure, the presence of upper airway swelling should be ascertained when deciding whether to extubate the patient in the operating room. Although no test has been proven to have high sensitivity and specificity in recognizing postoperative upper airway edema, the cuff leak test, 59 visual inspection of the airway 60 (e.g., laryngoscopy, bronchoscopy), and spirometry 50 (e.g., flow-volume loops on the anesthetic machine) are the most common tests used to assess the risk for extubation.…”