What is the management approach for a patient presenting with tongue swelling?

From the Guidelines

The management of a patient with tongue swelling requires prompt assessment and intervention based on severity, with a focus on maintaining airway patency and addressing the underlying inflammatory response. For mild to moderate cases, the approach should include administering antihistamines such as diphenhydramine 50 mg IV and H2 blockers like ranitidine 50 mg IV, as well as corticosteroids (methylprednisolone 125 mg IV) to prevent biphasic reactions 1. Secure the airway if respiratory distress is present, which may require supplemental oxygen, positioning the patient upright, and in severe cases, preparing for intubation or cricothyroidotomy. The use of epinephrine (0.1%) 0.3 mL subcutaneously or by nebulizer 0.5 mL may be considered if there is further increase in angioedema 1. It is also crucial to discontinue any potentially contributing medications, such as angiotensin-converting enzyme inhibitors (ACEIs), and provide supportive care. The management should be guided by the most recent and highest quality evidence, which emphasizes the importance of individualized observation periods and the potential need for skilled airway management 1. Key considerations include:

• Maintaining airway patency
• Administering antihistamines, H2 blockers, and corticosteroids
• Discontinuing potentially contributing medications like ACEIs
• Providing supportive care, including supplemental oxygen and positioning as needed
• Preparing for potential complications, such as the need for intubation or cricothyroidotomy. Given the potential for rapid progression and the importance of airway management, the most critical step is to ensure that the patient's airway is secure, which may involve close monitoring and the readiness to perform intubation or other airway interventions as necessary 1.

From the Research

Management Approach for Tongue Swelling

The management approach for a patient presenting with tongue swelling depends on the cause and severity of the swelling.

• The principal treatment of angioedema, a common cause of tongue swelling, is the discontinuation of the precipitating agent and airway management 2.
• Patients with swelling limited to the face and oral cavity may only require monitoring, while those with swelling in the floor of the mouth, tongue, and supraglottic or glottic areas should have their airway secured by tracheal intubation immediately 2.
• In cases of upper airway obstruction, the management depends on the cause of the obstruction, the training and skills of the rescuer, and the availability of adjuncts necessary to perform advanced airway techniques 3.
• Intubation should be attempted prior to surgical management of the airway in most cases of upper airway obstruction, and cricothyroidotomy or tracheostomy may be necessary to establish an airway in some cases 3.

Airway Management

• Airway management is critical in patients with tongue swelling, as it can lead to upper airway obstruction and respiratory distress 4, 5.
• Nasotracheal intubation, guided by a fiberoptic bronchoscope, may be necessary to establish an emergency airway in patients with severe lingual swelling 5.
• Manual decompression of the tongue and tactile nasal intubation may be used as a life-saving measure in cases of massive postoperative swelling of the tongue 6.

Treatment of Underlying Cause

• The treatment of the underlying cause of tongue swelling, such as hemorrhage, edema, infarction, or infection, is essential to prevent further complications 5.
• Medications such as dexamethasone may be used to treat swelling and reduce inflammation 5.