SESSION TITLE: Miscellaneous Case Report Posters II
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Multiple factors are responsible for acute tongue enlargement. Etiologic factor must be established because acute enlargement of tongue may cause upper airway obstruction or necrosis of tongue.
CASE PRESENTATION: A 64 year old male patient admitted to ICU for witnessed seizure and left side hemiparesis requiring endotracheal intubation for airway protection and large doses of benzodiazepine for seizure control. No evidence of tongue injury noticed. In addition to benzodiazepins, He was also started on scheduled dose of fosphenytoin and levetiracetam. He continued to have seizures as evident by clinical activity and continuous electroencephalogram monitoring. It was then decided to place the patient in a drug induced coma with pentobarbital sodium. Two days after starting him on pentobarbital sodium he developed massive tongue swelling with protrusion. After adequate seizure control, pentobarbital sodium was tapered off and the tongue swelling along with protrusion gradually improved over a week. Later in his hospital course he again developed status epilepticus and was placed in pentobarbital induced coma. Three days after restarting pentobarbital sodium he again developed massive tongue swelling with protrusion. Pentobarbital sodium was tapered over few days after and over time his massive tongue swelling with protrusion had improved. In between these two events tracheostomy was performed. It is to note his hospital stay was further complicated by multiple organ failure secondary to sepsis and given his poor prognosis his family had decided to opt for palliative care.
DISCUSSION: Macroglossia is a relatively rare condition. Most common acute causes in adults are trauma; prolong mechanical compression due to endotracheal tube, regional venous obstruction secondary to various head position during Head and Neck surgeries, hematoma, abscess, angioedema and hypersensitivity reaction. Angioedema is one of the known adverse effects of barbiturates but not as isolated tongue swelling. The etiology of massive tongue swelling in our patient is not clear but we postulate reason being restricted angioedema secondary to pentobarbital or its vehicles based on two occurrences with temporality. Acute tongue enlargement is critical event and emergent protection of airway is crucial. Acute swelling of the tongue can also compromise the blood flow to tongue itself secondary to mechanical compression, leads to tongue necrosis.
CONCLUSIONS: Physician must be observant about unexplained acute tongue enlargement and put best effort to identify factors in order to prevent complication associated with it.
Reference #1: Vogel, J.E., J.B. Mulliken, and L.B. Kaban, Macroglossia: a review of the condition and a new classification. Plast Reconstr Surg, 1986. 78(6): p. 715-23.
Reference #2: Ji, T., et al., Massive tongue swelling in refractory status epilepticus treated with high-dose pentobarbital. Neurocritical care, 2009. 10(1): p. 73-75.
DISCLOSURE: The following authors have nothing to disclose: Darshan Patel, Gurpreet Johal, Justin Ranes
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