<p>Acute Macroglossia Post Craniotomy in Sitting Position: A Case Report and Proposed Management Guideline</p>

Abstract

Background: Macroglossia is a rare life-threatening postoperative complication in patients undergoing neurosurgical operations in a sitting position. It is difficult to identify the cause of macroglossia, which can be considered multifactorial in most patients. Case Presentation: We herein present a case of a 37-year-old female patient who was known to have a posterior occipital lesion (low-grade glioma with pilocytic features) and underwent occipital craniectomy followed by supratentorial approach for debulking of the tumor under general anesthesia in a sitting position. The patient developed upper airway edema along with extreme macroglossia immediately following extubation, with increasing difficulty in ventilation. Re-intubation was impossible, and urgent tracheostomy was performed. In the intensive care unit (ICU), the macroglossia worsened, and the patient developed sepsis with multi-organ failure and died 16 days postoperatively. Conclusion: Acute macroglossia can be a catastrophic postoperative complication, necessitating early identification and a systematic approach to this critical event, in addition to being fully prepared to deal with difficult airway should this complication occur.

Acute airway obstruction requiring nasotracheal intubation following hypoglossal neuromonitoring: a case report

“…Generally, causes of acute lingual swelling include hemorrhage, edema, infarction, and infection [ 7 ]. Post operative macroglossia is a known complication of neurological procedures, especially among craniotomies conducted in the sitting position [ 8 , 9 ]. In these cases, extreme neck flexion likely resulted in impaired venous drainage of the tongue leading to edema.…”

“…This technique has been utilized by other studies requiring placement of an emergency airway in patients suffering from acute macroglossia [ 15 , 16 ]. Urgent cricothyroidotomy should be reserved as a last option but may be required in the setting of severe airway obstruction, especially if complicated by laryngeal edema [ 9 ]. In this case the lingual edema was successfully treated with supportive care and corticosteroids to decrease the inflammatory response.…”

Study of postoperative laryngopharyngeal discomfort: protocol for a single-centre cohort study

“…(1) Surgical factors: (a) surgical position that causes gravity to be distributed to the mouth and face; (b) head and neck flexion position, such as the prone position or posterior fossa surgery in the beach chair position, which leads to blockage of venous and lymphatic return 8 ; (c) surgical trauma that changes the permeability of vascular endothelial cells in the inflammatory state of the body and causes water retention; and (d) some surgical procedures that involve potential compression of the airway wall (cervical spine, thyroid, etc). (2) Aesthetic factors: (a) repeated or unskilled intubation 9 ; (b) compression of the tracheal tube on the intraoral tissue and airway during the operation 10 11 ; (c) method of endotracheal intubation, catheter type, tube size and material 6 12 ; (d) additional mechanical compression such as those caused by teeth, intraoral instruments, ultrasound probes, oropharyngeal airways, or throat packs 12 ; and (e) fluid overload. 13 (3) Patient factors: (a) duration in high-risk positions and (b) difficult airway (narrow oropharyngeal cavity or conditions that cause difficulty in intubation).…”

Macroglossia after Removeal of a Tumor of the Posterior Cranial Fossa. A Case Report

“…Тяжелая послеоперационная макроглоссия (ПМ) -довольно редкое осложнение после проведения интракраниальных оперативных вмеша-тельств� Впервые о ПМ упоминается в 1974 г� как о позиционном осложнении при оперативном вмешательстве в положении сидя [7]� ПМ -это впервые возникшая макроглоссия, которая может развиться в течение нескольких часов или дней после оперативного вмешательства, требующая продленного нахождения в отделении реанимации и интенсивной терапии (ОРИТ) (более 24 ч) для проведения специализированного лечения [3]� Развитию ПМ, как правило, предшествуют следующие факторы: орофарингеальная интубация, длительность вмешательства более 2 ч, давление, оказываемое на ткань языка различными приспособлениями (роторасширитель, интубационная трубка, ларингеальная маска [15], тугое тампонирование ротовой полости и т� д�), положение сидя на операционном столе [1,4], некорректное положение пациента [12,17]� В большинстве описанных случаев макроглоссия развивалась немедленно или в течение первых 48 ч после завершения операции [2]� Длительность отека составляла в среднем 3-5 сут, максимально -до 12 нед� Основное число наблюдений -у детей, что, вероятно, связано с их морфофункциональными особенностями (относительно большая голова и ко-роткая шея, повышенная гидрофильность тканей) [2,5,11]�…”