What is the best course of treatment for a patient with a swollen mouth and tongue, potentially due to an allergic reaction or infection?

Swollen Mouth and Tongue: Emergency Management

Immediate Airway Assessment and Intervention

If a patient presents with swollen mouth and tongue, the absolute priority is securing the airway immediately if there is any involvement of the floor of mouth, tongue base, supraglottic or glottic areas—proceed directly to endotracheal intubation without delay. 1, 2

Critical Decision Points for Airway Management

• Intubate immediately if swelling involves the floor of mouth, tongue base, or any laryngeal structures, as early intubation decreases the need for emergent surgical airways 2
• Patients with swelling limited only to the face and anterior oral cavity may be monitored closely without immediate intubation 2
• If laryngeal involvement is present or suspected, administer treatment and transfer to emergency care simultaneously 1
• Be prepared for difficult intubation—tongue swelling can make securing an adequate airway challenging, and jewelry (if present from oral piercings) must be removed or secured to prevent aspiration 1

Determine the Underlying Cause

Angioedema (Most Life-Threatening)

Orolingual angioedema, particularly ACE inhibitor-associated or post-thrombolysis angioedema, requires immediate recognition as it can be fatal if airway management is delayed. 1, 2, 3

• Post-thrombolysis angioedema occurs in 1.3% to 5.1% of patients, often unilateral and contralateral to the affected hemisphere 1
• ACE inhibitor-associated angioedema is self-limiting and typically resolves in 2-3 days after discontinuing the offending agent 2
• Risk increases with ACE inhibitor use and frontal/insular strokes 1

Initial treatment for angioedema:

• Discontinue the precipitating agent immediately 2
• Administer corticosteroids (prednisone per FDA indications for severe allergic conditions) 1, 4
• Administer antihistamines (diphenhydramine IV per FDA indications for allergic reactions) 1, 5
• Administer epinephrine if laryngeal edema is suspected 3
• Secure airway as described above 1, 2

Allergic Reaction

• Most commonly caused by bee/wasp stings, medications, or foods (eggs, shellfish, nuts) 3
• Often accompanied by urticaria in approximately 50% of cases 3
• Treatment mirrors angioedema management: antihistamines, corticosteroids, and epinephrine if severe 3

Infection (Ludwig Angina or Tongue Abscess)

Ludwig angina is a rapidly spreading oral cellulitis that can follow tongue piercing or dental trauma and requires aggressive management. 1

• Presents with tongue swelling, throbbing pain radiating to ears, fever, difficulty swallowing, drooling, and respiratory distress 6
• Treatment requires: maintaining adequate airway, systemic antibiotics covering gram-positive and gram-negative anaerobes, and surgical drainage of abscesses 1, 6
• Tongue abscesses are rare due to rich vascular supply but can compromise the airway 6
• Incision and drainage under general anesthesia with irrigation using normal saline and 2% hydrogen peroxide 6

Post-Procedural Complications

• Tongue swelling can occur after oral surgery, even procedures of short duration 7
• May develop in recovery room and progress rapidly 7
• Requires careful monitoring and readiness for reintubation 7

Supportive Oral Care During Recovery

Once the airway is secured and acute treatment initiated:

• Apply white soft paraffin ointment to lips every 2 hours for protection and moisturization 8, 9
• Clean mouth daily with warm saline mouthwashes to reduce bacterial load 8, 10
• Use anti-inflammatory oral rinse containing benzydamine hydrochloride every 3 hours, particularly before eating 8
• Apply antiseptic oral rinse such as 0.2% chlorhexidine digluconate mouthwash twice daily 8
• For fungal superinfection, use nystatin oral suspension 100,000 units four times daily for 1 week 8

Pain Management

• Use topical anesthetic preparations such as viscous lidocaine 2% (15 mL per application) for inadequate pain control 8
• Systemic analgesics may be necessary depending on severity 8

Avoidance Measures

• Avoid alcohol-containing mouthwashes which cause additional pain and irritation 8, 10
• Eliminate irritating foods including tomatoes, citrus fruits, hot drinks, and spicy, hot, raw, or crusty foods 10
• Avoid smoking and alcohol which impair healing 10

Monitoring and Follow-Up

• Daily oral review is necessary during acute illness 8
• Evaluate treatment response within 2 weeks; if no improvement, reevaluate diagnosis or consider alternative treatments 8, 10
• Be vigilant for signs of secondary infection or complications 8, 10
• Angioedema typically resolves spontaneously in 2-3 days, preventing unnecessary tracheostomy if properly managed 2

Common Pitfalls

• Delaying intubation in patients with floor of mouth or laryngeal involvement—this is the most critical error and can result in death 2, 3
• Failing to identify ACE inhibitor use in patients with angioedema 2, 3
• Using petroleum-based products chronically on lips, which promote mucosal dehydration and increase secondary infection risk 10
• Inadequate pain management impacting nutrition and hydration 8
• Performing extubation too early before swelling has adequately resolved 7