Pharyngeal Packs Can Cause Massive Swelling of the Tongue after Neurosurgical Procedures

Masahiko Kawaguchi, M.D., Department of Anesthesiology.Takanori Sakamoto, M.D., Department of Anesthesiology.Hideyuki Ohnishi, M.D., Department of Neurosurgery.Jun Karasawa, M.D., Department of Neurosurgery, Osaka Neurological Institute, 2-6-23 Shonai-Takaramachi, Toyonaka, Osaka 561, Japan.To the Editor:--Massive swelling of the tongue has been reported after neurosurgical procedures. [1-4]Mechanical obstruction of venous and lymphatic drainage of the tongue due to prolonged flexion of the neck and use of an oral airway and tracheal tube has been suggested as a possible cause of massive swelling of the tongue. Recently, we managed a patient who underwent tracheotomy and removal of intracranial tumor while in the supine position and who had massive postoperative swelling of the tongue requiring partial glossectomy for treatment.The patient was a 28-yr-old, 60-kg man whose presenting complaints were headache, ophthalmalgia, and anosmia. Subsequent examination, including computed tomography, magnetic resonance imaging, and angiography, revealed an upper nasal cavity tumor extending into the frontal cranial fossa. His medical history was unremarkable. He was scheduled for resection of intracranial tumor, and the bifrontal transbasal and the transmaxillary approaches with tracheotomy were planned. He was premedicated with 0.5 mg atropine and 20 mg famotidine intramuscularly. Anesthesia was induced with 300 mg thiopental and 8 mg vecuronium, and the trachea was atraumatically intubated with an 8.0-mm ID Mallinckrodt tube. Anesthesia was maintained with nitrous oxide in oxygen, isoflurane, and fentanyl. Tracheotomy was performed, and the tracheal tube was gently removed. No mechanical trauma of the tongue or pharynx was noted. The head was secured within a Mayfield three-point head-holder, and the body was placed in the supine position with a natural neck position. Pharyngeal packs with eight pieces of gauze were placed to prevent the entry of blood, secretion, and antiseptic solution into the stomach and trachea. The nasal and oral cavities were sterilized using povidone-iodine. Nothing was done via the intraoral route for surgery, and therefore anything like a mouth gag was not used. Surgery lasted for 11 h, and the intracranial tumor was totally resected. Anesthesia was uneventful. At the conclusion of surgery, pharyngeal packs, which were soaked with blood and secretions, were removed. The patient's tongue was noted to be slightly larger than normal but was not protruding from his mouth. The patient was transferred to the intensive care unit. Over the next 2 h, his tongue swelled markedly and came to protrude from his mouth. Methylprednisolone (250 mg) was given intravenously. He was sedated, and his lungs were mechanically ventilated. Over the next 7 days, the patient's tongue continued to swell, and large quantities of mucous secretion were discharged from the oral cavity. A portion of the tongue became necrotic (Figure 1). Over the next 12 days, although the swelling of the tongue receded slowly, mucous secretion continued to be discharged, and the necrotic portion of the tongue enlarged. On the 20th day after operation, partial glossectomy was performed. Although meningitis and pneumonia developed during the postoperative period, 8 months after the first operation, he was discharged with no neurologic deficits other than anosmia.Because the neck was not flexed and no tracheal tube was present during operation in this case, the cause of massive swelling of tongue was considered to be mechanical obstruction of venous and lymphatic drainage by pharyngeal packs during prolonged surgery. Usually we placed pharyngeal packs with two or three pieces of gauze during transphenoidal and transmaxillary approach. However, because tracheotomy was performed, and the orotracheal tube was removed in the present case, additional pieces of gauze were placed in the pharynx. In addition, blood and secretion drainage into pharyngeal packs might promote obstruction of venous and lymphatic drainage of the tongue. The possibility of this serious complication should be kept in mind when pharyngeal packs are used.Masahiko Kawaguchi, M.D., Department of Anesthesiology.Takanori Sakamoto, M.D., Department of Anesthesiology.Hideyuki Ohnishi, M.D., Department of Neurosurgery.Jun Karasawa, M.D., Department of Neurosurgery, Osaka Neurological Institute, 2-6-23 Shonai-Takaramachi, Toyonaka, Osaka 561, Japan.(Accepted for publication May 15, 1995.)