How should I evaluate and manage a patient with acute tongue swelling?

Acute Tongue Swelling: Evaluation and Management

Immediate Airway Assessment and Stabilization

The first priority in acute tongue swelling is recognizing the potential for airway compromise and planning for advanced airway management, including surgical airway, particularly in patients with hoarseness, lingual edema, stridor, or oropharyngeal swelling. 1

Critical Airway Indicators Requiring Immediate Intervention

• Observe all patients with oropharyngeal or laryngeal involvement in a facility capable of intubation or tracheostomy. 1
• Monitor closely for signs of impending airway closure: change in voice, loss of ability to swallow, and difficulty breathing. 1
• Complete inability to swallow saliva or rapidly progressive swelling affecting the airway requires immediate emergency department transfer. 2
• Early intubation in patients with floor of mouth, tongue, and supraglottic/glottic swelling may decrease the need for emergent surgical airways. 3

Physical Examination Priorities

• Assess unilateral versus bilateral involvement: unilateral swelling suggests abscess or trauma, while bilateral suggests angioedema or systemic process. 4
• Perform thorough oral cavity examination using gauze to grasp the tongue for inspection of lateral surfaces and floor of mouth. 2
• Palpate entire floor of mouth bilaterally to identify masses, ulcers, or retained foreign material. 2
• Examine for fluctuance suggesting abscess formation. 5, 6
• Assess cervical lymph nodes, documenting presence, size, mobility, and number. 4

Etiology-Specific Management

Anaphylaxis-Related Angioedema

For anaphylaxis causing tongue swelling, epinephrine is the definitive treatment:

• IV epinephrine 0.05 to 0.1 mg (5-10% of cardiac arrest dose) for patients not in cardiac arrest with IV access. 1
• IM epinephrine remains standard when IV access unavailable. 1, 7
• Continuous IV infusion (5-15 mcg/min) titrated to severity is reasonable for anaphylactic shock. 1
• Aggressive fluid resuscitation with 1000-mL boluses of isotonic crystalloid titrated to systolic BP >90 mmHg for vasogenic shock. 1
• Standard anaphylaxis treatments (corticosteroids, antihistamines) should be administered. 4

Critical caveat: Fatal epinephrine overdose has been reported; close hemodynamic monitoring is mandatory. 1

ACE Inhibitor-Associated Angioedema

• Discontinue the precipitating agent immediately. 3
• Standard angioedema treatments (epinephrine, corticosteroids, antihistamines) do NOT have significant effect on ACE inhibitor angioedema. 1
• Angioedema is self-limiting, typically resolving spontaneously in 2-3 days. 3
• Patients with swelling limited to face and oral cavity may only require monitoring, but those with floor of mouth, tongue, and supraglottic involvement require immediate intubation. 3

Hereditary Angioedema (HAE)

For HAE-related tongue swelling, specific targeted therapy is required:

• Three FDA-approved medications for acute HAE attacks: plasma-derived C1 inhibitor (C1INH), icatibant (B2 bradykinin receptor antagonist), and ecallantide (plasma kallikrein inhibitor). 1
• C1INH (BERINERT) 20 IU/kg IV achieves median time to initial symptom relief of 0.25 hours for laryngeal attacks. 8
• On-demand treatment is most effective when administered as early as possible. 1
• Epinephrine, corticosteroids, and antihistamines do NOT have significant effect on HAE swelling. 1
• Fresh frozen plasma can be used but may worsen symptoms and carries viral transmission risk. 1

Infectious Causes (Tongue Abscess)

• Tongue abscess is rare but potentially life-threatening due to airway compromise. 5, 6
• Clinical presentation includes fluctuant swelling, throbbing pain, fever, difficulty swallowing, and drooling. 5
• Needle aspiration or incision and drainage under general anesthesia is required. 5, 6
• Antibiotic coverage should include gram-positive and gram-negative anaerobes. 5
• Consider Ludwig angina in patients with tongue piercing history, requiring systemic antibiotics and surgical drainage. 4

Post-Thrombolysis Angioedema

• Occurs in 1.3-5.1% of stroke patients receiving thrombolytics, typically unilateral and contralateral to affected hemisphere. 4
• Treat with standard anaphylaxis protocol including corticosteroids, antihistamines, and possible intubation. 4

Diagnostic Workup

Imaging Strategy

• CT scan has 90-100% sensitivity for detecting foreign bodies versus plain radiography's poor sensitivity (false-negative rates up to 47% for esophageal foreign bodies). 2
• CT useful for evaluating extent of swelling and identifying abscesses. 5

Laboratory Evaluation

• Obtain full blood count to rule out hematologic disorders. 9
• Check coagulation studies if intervention planned. 9
• Measure fasting blood glucose to assess risk of invasive fungal infections. 9

Urgent Referral Indications

• Refer to ENT urgently if any mass, ulceration, or asymmetry detected on examination. 2
• Refer urgently if symptoms persist despite conservative management. 2

Common Pitfalls to Avoid

• Do not delay intubation in patients with floor of mouth or supraglottic involvement—early intubation prevents emergent surgical airways. 3
• Do not use standard anaphylaxis treatments for HAE or ACE inhibitor angioedema—they are ineffective. 1
• Do not assume tongue abscess is impossible due to rich vascular supply—it can occur and requires drainage. 5
• Do not perform unnecessary tracheostomy for ACE inhibitor angioedema—it is self-limiting within 2-3 days. 3

Conservative Management While Awaiting Specialist Evaluation

• Advise soft, moist, low-acidity diet. 2
• Warm saline mouth rinses three times daily. 2
• Aggressive hydration for third-space fluid sequestration. 1
• Narcotic medications for pain control if needed (avoid potent narcotics like fentanyl patches or oxycodone out-of-hospital). 1