Macroglossia in neurosurgery

Abstract

Macroglossia, an abnormal swelling of the tongue, is a rare post-operative complication often associated with serious airway obstruction and prolonged intubations. Currently, there is a paucity of information on the true incidence, aetiology, and complications associated with macroglossia. A thorough review of the literature was carried out so as to summarise the characteristics of reported cases of macroglossia and to present potential treatments and preventive strategies. A literature search was conducted in PubMed to identify human case reports of macroglossia after neurosurgical procedures including spine, published in English from 1974 to December 2015. A total of 26 reports with 36 cases of macroglossia were identified. Macroglossia was most commonly reported after sub-occipital and/or posterior fossa craniotomies and spine surgeries in prone or park-bench positions. It is more common after procedures lasting >8 h. The aetiology of macroglossia is multi-factorial and possible mechanisms included local mechanical tongue compression interfering with venous and/or lymphatic drainage, regional venous thrombosis and/or local trauma. Complications included airway obstruction, re-intubation, difficult re-intubation, prolonged intubation and Intensive Care Unit stay and tongue necrosis. Prevention, awareness of the possibility, and early recognition are the best forms of treatment.

Macroglossia secondary to prolonged prone positioning for management of COVID-19 respiratory failure

“…Macroglossia has been described in the literature as a rare complication of spinal and neurosurgical procedures, particularly those in the prone, park-bench and sitting positions as well as those lasting longer than 8 hours. 5 Proposed pathophysiology includes mechanical obstruction of lymphatic, venous and arterial flow; local ischaemia and reperfusion…”

“…injury. 5 Patients with COVID-19 receiving prolonged proneposition ventilation are especially at increased risk, 7 and there are no guidelines for managing such patients in whom standard lingual compressive therapy has failed. This case highlighted an effective method of lingual compression in patients with post-COVID-19 macroglossia.…”

“…3 4 It may lead to complications such as pain, chronic tongue drying, superimposed infection, impaired speech, swallow dysfunction and even airway obstruction. 5 Etiologies include endocrinological, metabolic or neoplastic infiltration; infectious or inflammatory conditions; trauma; and, rarely, prolonged prone positioning. 6 There are currently no standard guidelines for the management of acute macroglossia.…”

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

“…Remarkably, airway management can be challenging, and securing the airway in these patients is critical, which may require a surgical airway in many cases. 12 Thus, several preventive measures for this serious complication should be addressed.…”

“…13,14 In addition, reducing surgical time as much as possible, avoiding extreme flexion, placing a bite block between the teeth, and avoiding oral instrumentation, throat packs and oral airways, in order to avoid overcrowding of the mouth and tongue depression. 12,15,16 Proper positioning, intraoperative monitoring, and frequent assessment of the face and oral cavity intraoperatively can help in early detection. Moreover, simultaneous monitoring of central and jugular venous pressure can help in the assessment of hydration status and early detection of venous obstruction.…”