What is the initial workup and management for a patient presenting with tongue swelling?

Workup for Tongue Swelling

Immediately assess airway patency and secure the airway if there is any involvement of the floor of mouth, tongue base, or supraglottic structures—early intubation is critical before progressive swelling makes it impossible. 1

Immediate Airway Assessment

• Patients with swelling limited to the anterior tongue and oral cavity may only require close monitoring, but those with floor of mouth, posterior tongue, or supraglottic involvement require immediate tracheal intubation. 1
• Early intubation in patients displaying these characteristics decreases the incidence of emergent surgical airways and reduces mortality. 1
• Assess for stridor, drooling, difficulty swallowing, shortness of breath, and deliberate tongue fixation due to pain—these indicate impending airway compromise. 2

Critical History Elements

• Medication history is essential: specifically ask about ACE inhibitors (lisinopril, enalapril), as ACE inhibitor-associated angioedema is a common and potentially fatal cause. 1
• Document timing: ACE inhibitor angioedema can occur at any time during therapy, not just at initiation. 1
• Ask about recent thrombolytic therapy (tissue plasminogen activator), as post-thrombolysis orolingual angioedema occurs in 1.3-5.1% of patients, with unilateral tongue swelling typically contralateral to the affected hemisphere in stroke patients. 3
• Inquire about recent oseltamivir (Tamiflu) use, as this is a rare but documented cause. 4
• Assess for trauma history, including tongue piercings, which can cause Ludwig angina (rapidly spreading oral cellulitis). 3
• Document fever, local throbbing pain radiating to ears, and duration of symptoms to distinguish infectious from allergic etiologies. 5, 2

Physical Examination Specifics

• Examine for fluctuance on palpation, erythematous borders, and localized swelling—these indicate tongue abscess requiring drainage. 5, 2
• Assess for unilateral versus bilateral involvement: unilateral swelling suggests abscess or trauma; bilateral suggests angioedema or systemic process. 3
• Evaluate for cyanosis of the tongue, which may indicate venous obstruction. 6
• Perform cervical lymph node examination documenting presence, size, mobility, and number. 7

Diagnostic Workup

• Needle aspiration of suspected pus collection is both diagnostic and therapeutic, providing immediate symptom relief. 5
• In acute presentations with clear clinical signs (fluctuance, fever, localized pain), the diagnosis of tongue abscess can be reached clinically without imaging. 5
• CT or MRI of the head and neck should be obtained if deep muscle involvement, retropharyngeal extension, or Ludwig angina is suspected. 7
• Chest X-ray may be indicated if aspiration or mediastinal extension is a concern. 7

Immediate Management Algorithm

For ACE inhibitor-associated angioedema:

• Discontinue the precipitating agent immediately. 1
• Administer corticosteroids and antihistamines (standard anaphylaxis treatment). 3
• Recognize that angioedema is self-limiting and typically resolves spontaneously in 2-3 days—this prevents unnecessary tracheostomy. 1
• Secure airway early if floor of mouth or posterior tongue involvement; do not wait for progression. 1

For suspected tongue abscess:

• Transfer to operating room for incision and drainage under general anesthesia. 2
• Irrigate pocket with normal saline and 2% hydrogen peroxide. 2
• Antibiotic coverage must include gram-positive and gram-negative anaerobes. 2
• Expect approximately 30mL of thick pus drainage in typical cases. 2

For post-thrombolysis angioedema:

• Standard anaphylaxis treatment with corticosteroids, antihistamines, and possible intubation. 3
• Note increased risk with concurrent ACE inhibitor use and frontal/insular strokes. 3

Critical Pitfalls to Avoid

• Do not delay intubation in patients with floor of mouth or posterior tongue involvement—waiting for "progression" often results in a cannot-intubate-cannot-ventilate scenario requiring emergent surgical airway. 1
• Do not perform unnecessary tracheostomy in ACE inhibitor angioedema, as it resolves spontaneously within 2-3 days once the medication is stopped. 1
• Tongue abscess is rare due to the tongue's rich vascular supply and lymphatic drainage, but when present in immunocompromised patients, it can rapidly progress to airway compromise and disseminated infection. 5
• In patients with tongue piercings presenting with tongue swelling, consider Ludwig angina—this requires systemic antibiotics and surgical drainage of abscesses. 3