IATROGENIC MACROGLOSSIA FOLLOWING TRAUMATIC INTUBATION

Abstract

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Acute onset macroglossia is a rare yet life-threatening complication that may result from numerous etiologies including patient positioning while under anesthesia, oropharyngeal packing, local trauma, postoperative from surgery in the oral cavity, or secondary to allergic or nonallergic angioedema. Several management strategies have been described including utilization of reduction glossectomy. We present a rare case of acute onset macroglossia likely caused by traumatic intubation with multiple attempts and further potentiated by prone positioning. CASE PRESENTATION: Patient is a 55-year-old female with a past medical history of hypertension, COPD, OSA, HFpEF who presented with a one-week history of worsening shortness of breath. Vital signs showed T 97.6, BP 140/89, RR 24, O2 saturation 96% on 40% FiO2 on BiPAP. Physical exam demonstrated decreased air entry bilaterally with faint wheezing and crackles. Imaging suggested findings of pulmonary edema.Patient was treated for a working diagnosis of COPD and HF exacerbation with nebulizer treatments, steroids, and diuretics. Initial ABG showed pH 7.287, pCO2 77, pO2 124. However, her requirements on BiPAP worsened and a repeat ABG showed pH 7.156, pCO2 105.9, pO2 91 on 60% FiO2. Due to the underlying acidosis and deteriorating mental status, decision was made to intubate. Patient underwent a difficult intubation by anesthesia with at least three failed attempts due to patient's airway being hypertrophied and anterior. They were finally able to place a 6 Fr ETT over a bougie. Hospital course was further complicated by deteriorating respiratory status with ARDS and patient underwent multiple proning sessions. Around Day 7, patient was noted to have a protruding tongue that was undergoing excessive swelling. At its worse, the tongue was protruding three to four inches. The tongue was kept wet and covered with gauze. After stabilization, patient finally underwent tracheostomy about three weeks after intubation. Her status stabilized and she was transferred to another hospital for OMFS and ENT evaluation. Patient was treated with lingual compressive wraps as well as dexamethasone to normalization in a couple weeks. DISCUSSION: A review of literature did not show any cases that attributed multiple failed intubation attempts correlating with development of macroglossia. However, there have been some case reports attributing macroglossia to prone positioning. Typically, when macroglossia is of this magnitude, it requires reduction glossectomy by OMFS. However, our patient was treated conservatively with lingual compression wraps and steroids with return of tongue to baseline size making our case unique. CONCLUSIONS: Macroglossia is an extremely rare, yet almost forgotten complication that may be seen in intubated patients. The potential for it to be detrimental for the patient should always be in the back of our minds. REFERENCE #1: D. Saah, I. Braverman, J. Elidan, and B. Nageris, "Traumatic macroglossia," Annals of Otology, Rhinology & Laryngology, vol. 102, no. 9, pp. 729-730, 1993. REFERENCE #2: J. M. DePasse, M. A. Palumbo, M. Haque, C. P. Eberson, and A. H. Daniels, "Complications associated with prone positioning in elective spinal surgery," World Journal of Orthopaedics, vol. 6, no. 3, pp. 351–359, 2015. REFERENCE #3: R. Shanti, H. Braidy, and V. Ziccardi, "Application of maxillomandibular fixation for management of traumatic macroglossia: a case report," Craniomaxillofacial Trauma and Reconstruction, vol. 08, no. 04, pp. 352–355, 2015. DISCLOSURES: No relevant relationships by mohammed halabiya, source=Web Response No relevant relationships by William Meng, source=Web Response No relevant relationships by Richard Miller, source=Web Response No relevant relationships by Sushant Nanavati, source=Web Response No relevant relationships by Shawn Pate, source=Web Response No relevant relationships by Rutwik Patel, source=Web Response