Tongue necrosis is fortunately an extremely rare complication of endotracheal intubation, but the injury can be devastating. It’s important to recognize the patients at risk and to take precautions when securing an endotracheal tube to decrease the risk of injury.

Case Description

I saw this injury myself many years ago. I was called to the ICU to evaluate a patient for postoperative tongue pain. The patient was an otherwise healthy 41 year old who had undergone cervical spine decompression for tumor two days before. The patient had been in the prone, head flexed position in tongs during a surgery that had lasted about 7 hours. About 2 liters of crystalloid had been given and blood loss was less than 200 ml. Surgery had been successful and the patient had been extubated at the end of the case neurologically intact.

When the patient started talking to me, speech was terribly slurred. Almost the entire right side of the tongue was a pale brown and gray color, firm, and markedly edematous with an ulceration. Tongue necrosis was diagnosed. I don’t have a picture for this patient, but this photo, taken from an excellent review of tongue necrosis, is similar.

During the case, since neurostimulation was to be used to monitor spinal cord function, two fairly large, soft bite blocks made of rolled gauze had been placed to prevent the patient from chewing the tongue or mouth when stimulated. At the end of the case, the anesthesia team noted that the tongue looked a little swollen and that the tube had left an imprint over the back of the tongue.

 

In hindsight, these large bite blocks had apparently forced the endotracheal tube off center over the back of the tongue. With the endotracheal tube well taped at the corner of the mouth, and anchored in the trachea by the inflated cuff, we speculated that flexing the head forward had put the tube under tension. This effectively put a tourniquet over the base of the tongue and cutting off its blood supply. This has been reported in the literature.

 

The patient was treated with high dose steroids and supportive care. During recovery the patient suffered with weight loss, dysarthria, dyspahgia, decreased taste and decreased tongue sensation that delayed return to work. It took months but fortunately the patient recovered.

Predispostions To Tongue Necrosis

Any hard object in the mouth and compressing the tongue can interrupt blood flow. These can include poorly positioned endotracheal tubes, overinflated LMAs, malpositioned or poorly sized oral airways, the combination of an LMA with a hard oral airway, and surgical instruments such as the Dingman Gag— especially if they are used for a pronged period of time in a patient who is predisposed to poor blood flow to the tongue. Some of the predispositions to this injury include:

• Pre-existing medical conditions
  • Giant Cell Arteritis, coagulopathies, thrombosis
• Poor blood flow
  • Shock
• Elective controlled hypotensive anesthesia
• Poorly positioned endotracheal tube/oral airways/LMAs
• Surgical manipulations
  • Tongue retractors, neck flexion, prone position
• Swollen tongue
  • Trauma, hematoma, burn (heat/chemical)
  • Generous volume replacement
• Arterial and/or venous obstruction

The common theme for these predispositions is any thing that effectively decreases blood flow to the tongue can cause tongue necrosis.

When I was a resident, my instructors told me never to let the endotracheal tube cross from one side of the mouth to the other inside the mouth. The main reason was to avoid accidental extubation, since a tube taped at 21 cm at the teeth on the right side of the mouth will be too shallow if it also had to cross to the left side of the tongue on its way to the trachea. But as an aside, they also said that a tube crossing the tongue could easily cinch down and cut off the blood supply.

In the case of the patient that I saw, it was most likely the soft bite blocks meant to protect the patient that forced the endotracheal tube into such a position over the tongue. Combined with neck flexion and prone position it cut off the blood supply and caused the ischemia injury.

Outcomes

Fortunately tongues and mucous membranes have a high capacity for healing. However, it’s important to try to avoid such an injury because the potential for life long and severe disability is real, including:

• tongue scarring and deformity
• loss of tissue
• dysphagia can lead lead to weight loss from impaired ability to eat
• dysarthria: which may limit ability work and communicate
• decreased taste
• decreased tongue sensation

Treatment

Treatment is predominantly supportive. High dose steroids are often used. Antibiotics may be needed if infection develops. Even then, scarring and loss of tissue is common.

Prevention Of Tongue Ischemia

Prevention is therefore key.

• Careful attention to tube positioning
  • Don’t let the tube cross the back of the tongue
• Careful attention to oral airway positioning/size
• Avoid overinflation of LMAs
• Avoid pressure over the tongue when prone
  • Avoid hard oral airways when patient prone: It’s too easy for the oral airway tip to dig into the back of the tongue. You can always place one once the patient is supine again prior to extubation.
  • Use soft bite blocks when the patient is prone
  • Be careful with positioning soft bite blocks: check what they do to ETT positioning
• Be mindful of risk factors (e.g. shock, preexisting disease)
• Be mindful of fluid replacement when head dependent or when patient prone

Tongue necrosis from compression by an endotracheal tube or oral airway is rare, but devastating when it occurs. Other airway devices, such as oral airways, the LMA Supreme and the Fastrach intubating LM airway can also cause compression and ischemia injury. Click here for further discussion. We must be vigilant. It is within our power to minimize the risks.

May the Force Be With You

Christine Whitten MD
author Anyone Can Intubate: A Step by Step Guide, 5th Edition
and
Pediatric Airway Management: A Step by Step Guide

 

Further Reading

1. Roman BR, Immerman SB, Morris LGT, Ischemic Necrosis of the Tongue in Patients With Cardiogenic Shock. Laryngoscope. 2010 July; 120(7): 1345–1349.
2. Miura Y; Mimatsu K; Iwata H. Massive Tongue Swelling as a Complication After Spinal Surgery.  J Spinal Disord. Vol 9. No. 4 1996
3. Kuhn MA1, Zeitler DM, Myssiorek DJ. Tongue necrosis: a rare complication of oral intubation. Laryngoscope. 2010;120 Suppl 4:S159.
4. Nimjee S, Wright D. Tongue swelling and necrosis after brain tumor surgery. Asian J Neurosurg. 2012 Oct-Dec; 7(4): 214–216.
5. Lee P. Unilateral Tongue Swelling From Use Of The Laryngeal Mask Airway With The Guedel Airway As A Bite Guard. The Internet Journal of Anesthesiology. 2001 Volume 5 Number 4.

      

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