Macroglossia Associated with Brainstem Injury
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PRACTICAL PEARL
Macroglossia Associated with Brainstem Injury Ifeanyi Iwuchukwu • Agnieszka Ardelt • Wilson Cueva • Rwoof Reshi Fernando Goldenberg • Jeffrey Frank
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Published online: 4 September 2013 Ó Springer Science+Business Media New York 2013
Abstract Background Macroglossia has been reported in patients undergoing posterior fossa neurosurgical procedures and is thought to be as a result of venous engorgement from intubation or mechanical positioning during these prolonged procedures. Methods We report three patients who developed macroglossia and dysautonomia of central neurogenic origin following brainstem injury. Results The three patients developed macroglossia and dysautonomia with wide hemodynamic fluctuations in the setting of posterior fossa injury of the lower brainstem structures, necessitating tracheostomy placement. Macroglossia was managed with dexamethasone and there was complete resolution of dysautonomia while treated with beta-blockers and gabapentin. Conclusions Neurointensivists should be aware of macroglossia with dysautonomia complicating brainstem injury, which may have perilous consequences in the setting of cerebral edema or intracranial hypertension. Keywords Macroglossia Cerebral edema Dysautonomia Vasomotor center Somatoautonomic reflex
I. Iwuchukwu (&) Division of Neurocritical Care, Department of Neurology, Ochsner Medical Center, New Orleans, LA, USA e-mail: [email protected] A. Ardelt W. Cueva R. Reshi F. Goldenberg J. Frank Division of Vascular and Neurocritical Care, University of Chicago, Chicago, IL, USA
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Introduction There have been several reports of macroglossia following intubation for prolonged posterior fossa neurosurgical procedures [1–3]. Risk factors for the development of macroglossia include head positioning—park bench position, difficult intubation or laryngoscopy, and venous engorgement from endotracheal tube with or without gauze packing of the pharynx [1–4]. A few reports of macroglossia following posterior fossa surgery have raised a possible neurogenic etiology [2]. We report three cases of macroglossia associated with transient dysautonomia of putative central neurogenic origin. Patient 1 A 45-year-old female presented with a 1-year history of dysphagia and imbalance, and her evaluation revealed a dorsal pontomedullary cavernoma (Fig. 1a). Elective resection of the cavernoma was performed in the prone position, with the head gently flexed with the Mayfield apparatus. Postoperatively she developed tongue swelling and protrusion with limited tongue motility. Following reversal of anesthetic and neuromuscular blocking agents, she failed an immediate postoperative extubation trial due to worsening stridor and oxygen desaturation. Re-intubation was accomplished with a glidescope and the vocal cords were noted to be immobile. On postoperative day 1, she was noted to have hypotensive episodes unrelated to prior sedation. Her neurological examination off sedation showed she was awake and alert, following all commands with no motor limitati
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