What is the treatment for a swollen tongue?

Treatment of Swollen Tongue

The treatment of a swollen tongue depends critically on identifying and addressing the underlying cause, with immediate priority given to securing the airway if there are any signs of compromise, followed by targeted therapy based on etiology—infectious cases require antibiotics with anaerobic coverage (amoxicillin-clavulanate preferred), angioedema cases need antihistamines and corticosteroids with discontinuation of the offending agent, and all cases require close monitoring for progression. 1, 2

Immediate Assessment and Airway Management

First, assess for airway compromise by evaluating:

• Breathing difficulty, stridor, or respiratory distress 1, 2
• Extent of swelling (unilateral vs bilateral, anterior vs posterior tongue involvement) 2
• Ability to swallow secretions or presence of drooling 3
• Signs of Ludwig angina (bilateral submandibular swelling, floor of mouth elevation) 1, 2

If airway compromise is present or imminent, secure the airway immediately via intubation before swelling progresses. Early intubation prevents the need for emergent surgical airway. 4 Patients with swelling in the floor of mouth, tongue, and supraglottic areas require immediate tracheal intubation. 4

Determine the Underlying Cause

Assess for these key etiologies:

Infectious Causes

• Look for fever, erythema, fluctuance, purulent drainage, or localized tenderness 1, 3
• Check for recent trauma, tongue piercings, or dental procedures 1, 2
• Examine cervical lymph nodes for enlargement, tenderness, or mobility 2

Angioedema

• Review medication history, particularly ACE inhibitors (can cause angioedema even after years of use), angiotensin receptor blockers, or recent thrombolytic therapy 2, 5, 4
• Post-thrombolysis angioedema occurs in 1.3-5.1% of stroke patients, often with unilateral swelling contralateral to the affected hemisphere 2
• Drug-induced angioedema (oseltamivir, estramustine phosphate with ACE inhibitors) 6, 5

Abscess Formation

• Palpate for fluctuance, which indicates abscess requiring drainage 3
• Tongue abscesses are rare due to rich vascular supply but can occur, presenting with throbbing pain, fever, and difficulty swallowing 3

Treatment Based on Etiology

For Infectious/Inflammatory Swelling with Signs of Infection

Antibiotic therapy is the cornerstone:

• First-line: Amoxicillin-clavulanate provides excellent coverage against oral flora including anaerobes 1
• Penicillin-allergic patients: Doxycycline or fluoroquinolones PLUS metronidazole for anaerobic coverage 1
• Duration: 5-7 days for mild infections, 7-10 days for moderate infections 1

Local wound care:

• Apply 0.1% chlorhexidine solution rinses for 1 minute after initial assessment and daily during healing 1
• Cleanse with sterile normal saline 1
• Remove any foreign bodies such as piercing jewelry immediately 1
• Avoid spicy, acidic, or hot foods 1

For severe infections requiring hospitalization:

• IV antibiotics: ampicillin-sulbactam, piperacillin-tazobactam, or carbapenems 1
• Add vancomycin if MRSA risk factors present 1
• Immediate hospitalization indicated if Ludwig angina develops, abscess forms, or systemic toxicity/sepsis present 1

For Tongue Abscess

Requires surgical intervention:

• Incision and drainage under general anesthesia 3
• Irrigate pocket with normal saline and 2% hydrogen peroxide 3
• Approximately 30mL of thick pus may be drained 3
• Antibiotics covering gram-positive and gram-negative anaerobes 3

For Angioedema

Standard anaphylaxis treatment protocol:

• Corticosteroids and antihistamines 2
• Discontinue the offending medication immediately (ACE inhibitor, ARB, or other causative agent) 6, 5, 4
• Symptoms typically improve rapidly with antihistamines after drug discontinuation 6
• Angioedema is self-limiting, usually resolving spontaneously in 2-3 days 4
• Monitor closely as intubation may be required if progression occurs 2, 4

For Stevens-Johnson Syndrome/TEN with Oral Involvement

Supportive oral care:

• Apply white soft paraffin ointment to lips immediately, then every 2 hours 7
• Use mucoprotectant mouthwash (e.g., Gelclair) three times daily 7
• Clean mouth daily with warm saline mouthwashes or oral sponge 7
• Anti-inflammatory oral rinse with benzydamine hydrochloride every 3 hours, particularly before eating 7
• For severe pain: viscous lidocaine 2% (15 mL per application) or cocaine mouthwashes 2-5% three times daily 7
• Antiseptic oral rinse twice daily: 1.5% hydrogen peroxide or 0.2% chlorhexidine digluconate (may dilute by 50% to reduce soreness) 7

Monitoring and Follow-Up

Reassess within 48-72 hours:

• If no improvement, consider imaging or specialist consultation 1
• Daily assessment until fever resolves and swelling improves 1
• Monitor for development of complications such as abscess formation or airway compromise 1

Critical Pitfalls to Avoid

Do not delay antibiotic therapy while awaiting culture results in clinically infected wounds. 1 This is a common error that can lead to progression of infection.

Do not provide inadequate anaerobic coverage. Monotherapy with fluoroquinolones or cephalexin is insufficient for oral infections. 1 Oral flora includes significant anaerobic bacteria requiring appropriate coverage.

Do not underestimate airway risk. Tongue swelling can progress rapidly to complete obstruction. 1 What appears manageable can deteriorate within hours, particularly with Ludwig angina or post-thrombolysis angioedema.

Do not close infected wounds. Allow healing by secondary intention. 1

Severe pain disproportionate to physical findings may indicate deeper tissue involvement and requires prompt evaluation and possible imaging. 1