Association of Severe Tongue Edema With Prone Positioning in Patients Intubated for COVID‐19

Abstract

Objectives/Hypothesis Prone positioning is frequently used in patients intubated for COVID‐19‐related lung injury to improve oxygenation. At our institution, we observed severe tongue edema develop in some of these patients. Hence, we sought to determine the incidence of tongue edema in this cohort and whether prone positioning was a risk factor associated with this complication. Study Design Retrospective cohort study. Methods A single‐system retrospective cohort study of patients intubated for respiratory failure secondary to COVID‐19 who subsequently developed clinically notable tongue edema from March 13 to July 5, 2020. Results 260 patients were intubated for COVID‐19‐related respiratory failure during the study period. 158 patients (60.8%) underwent at least one episode of proning. Twelve patients in total (4.6%) developed clinically significant tongue edema. Eleven of the twelve patients (91.7%) who developed tongue edema underwent proning prior to the development of edema. Prone positioning was associated with an increased incidence of tongue edema (odds ratio [OR] 7.56, 95% confidence interval [CI] 0.96–59.46, P = .027). In all proned patients who developed edema, this complication was noted during proning or shortly after supination (range, 0–4 days). Tongue edema was primarily managed with conservative measures; one patient required tracheostomy for definitive management. Conclusions Tongue edema appears to develop in a subset of patients with COVID‐19 who are intubated. It appears to be associated with prone positioning but is likely multifactorial in nature. Further investigation into its incidence and pathophysiology is warranted. Level of Evidence 4 Laryngoscope , 2021

ENT symptoms in acute COVID-19: a narrative review

“…multisystem inflammatory syndrome and Kawasaki-like disease in children with COVID-19 21-23 . Furthermore, a substantial group of oral lesions are attributable to iatrogenic lesions, such as intubation injuries, drug reactions and opportunistic infections during SARS-CoV-2 infection 24 , 25 .…”

In Reference to Association of Severe Tongue Edema With Prone Positioning in Patients Intubated for COVID‐19

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We read with interest the article by Walsh et al and appreciate this study investigating prone position-related tongue edema in patients followed up in the intensive care unit. 1 However, we would like to contribute to this issue and present our criticisms of the authors' work.The authors stated that their study was the first in the literature to examine tongue edema in detail. However, we would like to point out that we have three clinical, prospective studies in which tongue edema caused by the rigid direct laryngoscope used in suspension laryngoscopy in adult patients and tongue edema due to the high pressure exerted on the tongue by the tonsillar retractor and tongue depressor used in pediatric patients who underwent tonsillectomy and adenoidectomy surgery were detected by ultrasonography (USG).

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“…We read with interest the article by Walsh et al and appreciate this study investigating prone position-related tongue edema in patients followed up in the intensive care unit. 1 However, we would like to contribute to this issue and present our criticisms of the authors' work.…”

In Response to Association of Severe Tongue Edema With Prone Positioning in Patients Intubated for COVID‐19

“…We would like to thank Dr Onal and Dr Onal for their interest in our article and discussion regarding the topic of tongue edema. 1,2 We acknowledge that prior studies, including their own, have examined tongue edema in other settings. Dr Onals's work on tongue edema in pediatric patients undergoing tonsillectomy and in adult patients undergoing suspension laryngoscopy illustrates that tongue edema can develop in a variety of patient populations.…”