Acute Unilateral Tongue Swelling: Immediate Management
This patient requires immediate airway assessment and consideration of tongue abscess as the primary diagnosis, with urgent imaging and preparation for potential surgical drainage under controlled airway conditions.
Immediate Airway Evaluation
- Assess for signs of impending airway compromise immediately: voice changes, inability to swallow, stridor, difficulty breathing, or drooling 1
- Monitor in a facility capable of emergency intubation or tracheostomy, as tongue swelling can progress rapidly and unpredictably 1
- Consider early elective intubation if any signs of progression appear, as waiting until complete obstruction makes intubation extremely difficult due to distorted anatomy 1
- Avoid unnecessary instrumentation of the airway, as this can worsen swelling 1
Primary Differential Diagnosis: Tongue Abscess
Tongue abscess is the most likely diagnosis in a healthy 40-year-old female with acute unilateral tongue swelling, particularly on the left side under the tongue 2, 3, 4
Key Clinical Features Supporting Abscess:
- Acute onset of unilateral tongue swelling 2, 3
- Typically presents with severe throbbing pain, difficulty swallowing, and potential fever 3
- May have fluctuant swelling on palpation with erythematous borders 3
- Can occur spontaneously even without trauma, especially in the anterolateral tongue 3, 4
- This is a potentially life-threatening infection requiring urgent intervention 2, 3, 5
Diagnostic Approach:
- Obtain CT scan of the oral cavity and pharynx immediately to confirm abscess and assess extent 4, 5
- Needle aspiration can provide both diagnostic confirmation and therapeutic relief 2
- Physical examination may reveal fluctuance, but imaging is key to diagnosis and surgical planning 5
Immediate Medical Management
If Abscess is Suspected:
- Start broad-spectrum IV antibiotics immediately covering gram-positive, gram-negative, and anaerobic organisms 3, 5
- Provide IV hydration 3
- Administer appropriate analgesia 3
- Prepare for urgent surgical drainage under general anesthesia with controlled airway 3, 5
Alternative Diagnosis: Angioedema
If the presentation suggests angioedema rather than abscess (rapid onset, no fever, possible urticaria):
- Administer IM epinephrine 0.3 mg immediately 1, 6
- Give IV diphenhydramine 50 mg 1, 6
- Administer IV methylprednisolone 125 mg 1, 6
- Add H2-blocker: ranitidine 50 mg IV or famotidine 20 mg IV 1, 6
- Check for ACE inhibitor use; if present, consider icatibant 30 mg subcutaneously 1, 6
Definitive Treatment for Tongue Abscess
- Incision and drainage under general anesthesia is the definitive treatment 3, 5
- Secure the airway first before any surgical intervention 3, 5
- Irrigate the abscess cavity with normal saline and hydrogen peroxide 3
- Continue IV antibiotics covering anaerobes post-drainage 3, 5
- Multi-antimicrobial therapy is the cornerstone, but surgical drainage is critical to prevent deeper spread 5
Critical Pitfalls to Avoid
- Never delay airway assessment and preparation - tongue abscesses can cause acute airway obstruction 2, 3, 5
- Do not assume trauma is required for tongue abscess formation; spontaneous cases occur, particularly in the anterolateral tongue 3, 4
- Posterior tongue abscesses (base of tongue) are more dangerous than anterior abscesses and require different surgical approaches 5
- Tongue abscesses are rare due to rich vascular supply and lymphatic drainage, but when they occur, they are emergencies 3
- Historical mortality rates for untreated tongue/laryngeal swelling approach 30% 1