What is the management for acute tongue swelling?

Management of Acute Tongue Swelling

For acute tongue swelling, immediately assess for airway compromise (stridor, hoarseness, oropharyngeal swelling) and secure the airway if present, while simultaneously determining the etiology to guide specific treatment—epinephrine for anaphylaxis-related angioedema versus icatibant or C1 inhibitor for bradykinin-mediated angioedema (ACE inhibitor-induced or hereditary angioedema). 1, 2

Immediate Airway Assessment and Management

Critical Signs Requiring Advanced Airway Planning

• Lingual edema with stridor, hoarseness, or oropharyngeal swelling mandates early planning for advanced airway management, including surgical airway 1
• Stridor indicates >50% airway diameter reduction and represents imminent airway compromise 1
• Once stridor develops, the window for safe intubation narrows rapidly 1
• Tongue edema can progress to complete airway obstruction 1

Extent of Swelling Assessment

• Edema limited to anterior tongue and lips may not require intubation 2
• Edema involving larynx, palate, floor of mouth, or oropharynx with rapid progression requires continued intubation 2
• Have reintubation equipment readily available, including airway exchange catheters for high-risk cases 2
• Consider cricothyroidotomy only as last resort, especially in patients receiving thrombolytics 2

Etiology-Specific Treatment

Anaphylaxis-Related Angioedema

Administer intramuscular epinephrine immediately 3

• Epinephrine is indicated for emergency treatment of allergic reactions causing airway swelling, laryngospasm, bronchospasm, and angioedema with swelling of lips and tongue 3
• Laryngeal edema with stridor occurs in up to 70% of anaphylaxis cases 1
• Death from food-induced anaphylaxis typically occurs within 30 minutes to 2 hours from cardiorespiratory compromise 1

Adjunctive medications:

• IV methylprednisolone 125 mg 2
• IV diphenhydramine 50 mg 2
• Ranitidine 50 mg IV or famotidine 20 mg IV 2
• If angioedema increases further, administer epinephrine (0.1%) 0.3 mL subcutaneously or by nebulizer 0.5 mL 2

ACE Inhibitor-Induced Angioedema (Bradykinin-Mediated)

This is a critical diagnostic pitfall: ACE inhibitor-induced angioedema does NOT respond to epinephrine, antihistamines, or corticosteroids 1

Specific treatment required:

• Icatibant (selective bradykinin B2 receptor antagonist) 30 mg subcutaneously in the abdominal area 2
• Additional injections may be administered at 6-hour intervals (maximum 3 injections in 24 hours) 2
• Plasma-derived C1 esterase inhibitor (20 IU/kg) may be considered 2
• Discontinue ACE inhibitor immediately 2

Clinical presentation distinguishing features:

• Asymmetric, non-pitting swelling prominently involving face and tongue 1
• WITHOUT urticaria or pruritus (unlike anaphylaxis) 1
• Published reports document deaths from complete upper airway obstruction 1
• Swelling can continue for at least 6 weeks after drug discontinuation 1

Hereditary Angioedema

• Attacks involve face, tongue, and larynx 1
• Multiple genetic variants (HAE-FXII, HAE-PLG, HAE-ANGPT1) present with tongue and laryngeal involvement 1
• Treatment: Icatibant 30 mg subcutaneously or C1 esterase inhibitor (20 IU/kg) 2, 4
• Early treatment (within 1 hour of onset) reduces attack duration from 16.8 hours to 6.1 hours 4
• Patients with laryngeal, tongue, or throat swelling should self-administer treatment and seek emergency care 4

Infectious Causes Requiring Different Management

Tongue Abscess

• Presents with severe tongue pain, swelling (often unilateral), fluctuance on palpation, fever, difficulty swallowing, and drooling 5
• Diagnosis: Needle aspiration provides both diagnostic confirmation and therapeutic benefit 6
• Treatment: Incision and drainage under general anesthesia with airway secured 5
• Antibiotic coverage for gram-positive and gram-negative anaerobes 5
• Rare due to tongue's rich vascular supply and lymphatic drainage, but potentially life-threatening 6

Lingual Tonsillitis

• Viral infections account for 70-95% of cases (rhinovirus, coronavirus, adenovirus, influenza, EBV) 7
• Bacterial causes include Groups C and G beta-hemolytic streptococci, Mycoplasma pneumoniae, Chlamydia pneumoniae 7
• Lingual tonsillar hypertrophy commonly develops following palatine tonsillectomy as compensatory lymphoid hyperplasia 7

Post-Intubation/Post-Surgical Tongue Swelling

Extubation Planning

• Begin corticosteroid therapy at least 12-24 hours before planned extubation in high-risk patients 2
• Perform leak test prior to extubation—negative leak test indicates increased laryngeal edema risk and should prompt continuation of dexamethasone 2
• Monitor closely post-extubation for stridor, difficulty breathing, oxygen desaturation, and tachypnea 2
• For post-extubation stridor from laryngeal edema, consider epinephrine nebulization 2

Post-Tonsillectomy Complications

• Massive tongue swelling can occur following bilateral tonsillectomy, causing airway obstruction 8
• Requires immediate reintubation and steroid administration 8
• Swelling may worsen over 24-48 hours before improvement 8

Critical Pitfalls to Avoid

1. Treating bradykinin-mediated angioedema with standard anaphylaxis medications—ACE inhibitor-induced angioedema requires icatibant or C1 inhibitor, NOT steroids, antihistamines, or epinephrine 1

2. Delaying airway intervention—once stridor develops, safe intubation becomes increasingly difficult 1

3. Large volume fluid resuscitation worsening airway swelling—makes early definitive airway management crucial 2

4. Confusing angioedema with other causes—post-extubation stridor can result from laryngeal injury, subglottic stenosis, or paradoxical vocal cord motion rather than angioedema 1

5. Missing infectious causes—tongue abscess should be considered in all cases of acute tongue swelling, especially with fever and unilateral fluctuant swelling 6