> The swollen tongue is a recurring clinical phenotype on the exams and has been asked multiple times on past OSCEs. see: [[Airway#anaphylaxis and angioedema|Angioedema difficult airway]], [[Awake fiberoptic intubation]], [[Tracheostomy|cricothyrotomy]] > [!pearl]- Exam relevance >This topic makes for a good exam question because it overlaps with several [[OSCE General Advice#Domains|Domains]] : *medical expertise* (what's the diagnosis and what is your approach to working it up?), *prioritisation and decision making* (recognition of airway risk and providing a safe and sensible airway plan), *health advocacy* (no one wants to admit the patient, how do you troubleshoot this? ICU says they can go to the ward, ENT doesn't want to come in and do FNE, etc), *leadership and management* (remediating a registrar who put the patient in SSU), or *scholarship and teaching* (teaching a resident about managing a swollen tongue) My approach to the swollen tongue is to divide it into discrete issues: 1. Emergency management of an unsafe [[Airway#anaphylaxis and angioedema|airway]] (priority) 2. Provide safe and appropriate early treatments 3. Workup for why the tongue is swollen ## Causes of a swollen tongue - [[Anaphylaxis]] - [[Seizures|seizure]] with tongue bite and haematoma - [[Airway#Burns airway|Airway burns]] or toxic inhalation (I've seen this from [[Solvents|chroming]] N2O and got cold burns) - B vitamin deficiency, in particular B12 from N2O excess, can lead to glossitis as well - Bee sting to tongue - TPA - ACE inhibitor [[Angioedema]] or primary angiodedema - [[Ludwig angina]] or other ENT catastrophe - glossitis - tongue cancer with a fungating or bleeding mass - infection - candida - immunocompromised bacterial infection - herpes (or post-herpetic glossitis) - malaria - Other medications - salbutamol - sulfra drugs - OCP - lithium ## Airway assessment - Keep patient upright in a safe/neutral airway position in resus **pre-oyxgenating** - Assess any imminent airway risks using a structured approach (eg [[Airway#LEMON|LEMON]]) - Assess for [[Airway#Difficult surgical airway assessment|Difficult surgical airway]] - Include appropriate consultations - ENT to assess airway with fibreoptic nasal examination - Anaesthetics for plan (eg [[Awake fiberoptic intubation]]) - Early ICU involvement as likely HDU disposition (or surveillance on the ward if airway is not critical) - Develop a structured plan with multiple redundancies if needing emergency intubation - generally RSI "she'll be 'right" is a bad idea unless there is a good reason to think it will be safe as a first attempt - RSI was an *automatic fail* on the [2014.1](x-devonthink-item://DF41347E-3ABD-4C5C-81BF-8C052F66A709?page=15) version of this question - hyperangulated D-blade is controversial : good indirect laryngeoscopy but can be mechanically difficult to pass ETT - early securement of airway in a progressively worsening airway -- simply "monitoring in ICU" is not necessarily the safest option - plan for [[Tracheostomy|surgical airway]] or two operator set up if initial non-surgical airway plan is unsuccessful ## Possible adjunct treatments tailored to the actual cause - usually dexamethasone 8mg IV - +/- adrenaline if suspect anaphylaxis (less effective for angioedema) - +/- [[TXA]] (↓ consumption of C1 esterase) - +/- [[Warfarin, DOAC, heparin reversal|anticoagulant reversal]] if on anticoagulation ## Address the underlying cause - Make sure to avoid [[Cognitive biases|premature diagnostic closure]] on the cause → don't just assume all tongue biting is anaphylaxis - If signs of a tongue bite with no obvious cause, workup for [[Seizures#First seizure workup|First seizure]] including CTB [^1] [^1]: This is not just a hypothetical; I have seen this occur myself secondary to ICH in a patient presenting with no neurological deficits, and I am aware of other first seizure misses presenting with tongue swelling treated as anaphylaxis