Attending Anesthesiologist Intensivist Cleveland Clinic Foundation Cleveland, Ohio, United States
Introduction: Postoperative macroglossia is a rare and serious complication following neurological procedures especially when patients are prone positioned. The incidence has been reported as 1% but could be underreported with an unclear true incidence. The management of airway obstruction secondary to postoperative macroglossia is challenging and often requires re-intubation or invasive airway management. We report a case of difficult airway secondary to severe postoperative macroglossia after a posterior fossa craniotomy.
Description: A 46-year-old female with history of micrognathia and obstructive sleep apnea presented for a posterior fossa craniotomy for a pineal mass. Macroglossia was noted when the patient was positioned supine for emergence. Patient met all the extubation criteria and was extubated in OR. Postoperative course was complicated by dysarthria and respiratory distress ten hours after extubation due to increase in tongue swelling causing upper airway obstruction. Her airway was secured by an awake nasal fiberoptic intubation using light sedation and topicalization with lidocaine. Patient was then admitted to the surgical intensive care unit and started on dexamethasone 10 mg IV every 8 hours. Her tongue swelling persisted despite steroids. Application of bite block and tongue massage further improved the anterior tongue swelling after 3 days. On POD-4, video laryngoscopy showed no swelling of larynx, hypopharynx, or base of tongue and nasotracheal tube was exchanged for oral endotracheal tube. She was extubated on POD-6 with airway exchange catheter (AEC) in place and continued bite block application. The AEC and bite block was later successfully removed when the patient was maintaining airway without any obstruction.
Discussion: Management of postoperative macroglossia is challenging. A vicious cycle of edema and pressure can lead to life-threatening upper airway obstruction, acute respiratory distress and prolonged ICU stay. The etiology is possibly multi-factorial with a combination of mechanical compression leading to venous and lymphatic obstruction, dependent edema due to prone positioning compounded by trauma during intubation. Use of nasotracheal intubation, bite block, tongue massage and AEC helped in a safe extubation and successful outcome in our patient.
