What is the appropriate management for a patient presenting with a swollen tongue, considering potential causes such as allergies, autoimmune disorders, or trauma, and the risk of airway compromise?

Management of Tongue Swelling

Immediately secure the airway with 100% oxygen, assess for signs of impending airway closure (voice change, inability to swallow, stridor, breathing difficulty), and administer epinephrine 50 mcg IV (0.5 mL of 1:10,000) as first-line treatment if angioedema is suspected. 1

Immediate Airway Assessment

The primary concern with tongue swelling is airway compromise, which can progress rapidly and unpredictably. 2, 1

Critical signs of impending airway closure include:

• Change in voice quality 3, 1
• Loss of ability to swallow 3, 1
• Stridor or difficulty breathing 3, 1
• Arterial oxygen desaturation 1

Position the patient head-up to reduce venous congestion and slow edema progression. 1 Call for immediate help, notifying senior personnel and activating peri-arrest protocols if airway compromise signs are present. 1

Avoid direct laryngoscopy or unnecessary airway manipulation, as trauma can worsen the angioedema. 3, 1 If intubation becomes necessary, awake fiberoptic intubation is optimal; nasal-tracheal intubation poses epistaxis risk, and cricothyroidotomy is rarely needed but problematic in this setting. 3

Determine the Underlying Etiology

Assess for unilateral versus bilateral involvement: unilateral swelling suggests abscess or trauma, while bilateral suggests angioedema or systemic process. 2

Key historical features to identify:

• Recent thrombolytic therapy: Post-alteplase orolingual angioedema occurs in 1.3-5.1% of stroke patients, typically presenting as unilateral tongue swelling contralateral to the affected hemisphere. 3, 2
• ACE inhibitor use: ACE inhibitor-associated angioedema can occur from hours to years after starting therapy and is a bradykinin-mediated process. 3, 4, 5
• Tongue piercing or recent trauma: Can lead to Ludwig angina, a rapidly spreading oral cellulitis requiring systemic antibiotics and surgical drainage. 3, 2, 6
• Allergic triggers: Foods, drugs, insect stings, or other allergens causing IgE-mediated anaphylaxis. 7
• Medication history: Rare cases reported with oseltamivir and estramustine phosphate combined with ACE inhibitors. 8, 4

Examine for fluctuance on palpation and erythematous borders, which suggest abscess formation requiring incision and drainage. 6 Assess cervical lymph nodes, documenting presence, size, mobility, and number. 2

Pharmacologic Management

For Suspected Allergic/Anaphylactic Angioedema

Administer epinephrine 50 mcg IV (0.5 mL of 1:10,000 solution) immediately as first-line treatment. 1, 7 Repeat doses every 3-5 minutes if severe hypotension, bronchospasm, or progressive angioedema persists. 1 Consider epinephrine infusion if multiple bolus doses are required given its short half-life. 1

Do not delay epinephrine administration while attempting to determine angioedema subtype—give it immediately. 1 Note that absence of cutaneous signs does not exclude anaphylaxis, as hypotension may be the sole feature in 10% of cases. 1

Administer adjunctive therapy:

• Diphenhydramine 50 mg IV for histamine-mediated component 3, 1, 9
• Methylprednisolone 125 mg IV (or hydrocortisone 200 mg IV) 3, 1
• Ranitidine 50 mg IV or famotidine 20 mg IV as H2-blocker 3, 1

For Post-Thrombolytic Angioedema

Discontinue IV alteplase infusion immediately and hold ACE inhibitors. 3 Administer the same regimen as allergic angioedema: methylprednisolone 125 mg IV, diphenhydramine 50 mg IV, and ranitidine 50 mg IV or famotidine 20 mg IV. 3

If angioedema continues to increase, administer epinephrine (0.1%) 0.3 mL subcutaneously or by nebulizer 0.5 mL. 3 For refractory cases, icatibant (selective bradykinin B2 receptor antagonist) 30 mg subcutaneously in the abdominal area may be administered, with additional injections at 6-hour intervals not exceeding 3 injections in 24 hours. 3

Endotracheal intubation may not be necessary if edema is limited to anterior tongue and lips, but edema involving larynx, palate, floor of mouth, or oropharynx with rapid progression (within 30 minutes) poses higher risk requiring intubation. 3

For ACE Inhibitor-Associated Angioedema

Discontinue the ACE inhibitor immediately. 3, 4, 5 Standard anaphylaxis treatment with antihistamines and corticosteroids should be administered, though these are less reliably effective for bradykinin-mediated angioedema. 3, 1 Do not rely solely on antihistamines and steroids if bradykinin-mediated angioedema is suspected. 1

For Infectious Causes (Ludwig Angina/Tongue Abscess)

Maintain adequate airway, administer systemic antibiotics covering gram-positive and gram-negative anaerobes, and perform surgical drainage of abscesses. 3, 2, 6 Antibiotic coverage should include agents effective against Pseudomonas aeruginosa, Staphylococcus aureus, and Streptococcus pyogenes. 3

Fluid Resuscitation and Hemodynamic Support

Administer normal saline 0.9% or lactated Ringer's solution at high rate via large-bore IV cannula. 1 Large volumes may be required if hypotension is present due to third-space fluid sequestration. 1 Elevate the patient's legs if hypotensive. 1

If hypotension persists despite epinephrine, consider alternative vasopressor such as metaraminol or noradrenaline infusion. 1

Observation and Monitoring

All patients with oropharyngeal or laryngeal tongue swelling must be observed in a medical facility capable of performing intubation or tracheostomy. 3 Continuous monitoring of vital signs, oxygen saturation, and airway patency is mandatory. 1

The observation period should be extended, as symptoms can develop up to 1 hour after exposure and recurrence can occur. 1 Patients should not be discharged until completely stable. 1 Monitor for post-obstructive pulmonary edema if significant airway obstruction occurred. 1

Problems from airway injury often do not become apparent until after intervention, making post-treatment monitoring critical. 10

Critical Pitfalls to Avoid

• Do not perform unnecessary direct visualization of the airway, as trauma from the procedure can worsen angioedema. 3, 1
• Do not delay epinephrine while determining the specific cause—administer immediately for any suspected angioedema with airway threat. 1
• Do not discharge patients with oropharyngeal involvement without adequate observation period. 1
• Do not assume the tongue is the only site of edema—assess for laryngeal, palatal, and floor of mouth involvement. 3