Case report
Tongue swelling in the recovery room: a case report and discussion of postoperative angioedema

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Abstract

We present a case of potentially life-threatening postoperative swelling of the tongue and oropharynx that developed in the postanesthesia care unit in a patient taking lisinopril. The principal treatment of angioedema is the discontinuation of the precipitating agent and airway management. Patients with swelling limited to the face and oral cavity may only require monitoring. However, those with swelling in the floor of the mouth, tongue, and supraglottic or glottic areas should have their airway secured by tracheal intubation immediately. Early intubation in patients displaying these characteristics may decrease the incidence of emergent surgical airways. Angioedema is self-limiting, and the swelling usually resolves spontaneously in two to 3 days. Proper identification of angiotensin-converting enzyme inhibitor–associated angioedema requiring a timely airway intervention may reduce mortality, and recognition of its self-limiting course can prevent unnecessary tracheostomy.

Introduction

Postoperative swelling of the tongue is a rare but potentially life-threatening situation. Cases of angioedema occurring in a patient on angiotensin-converting enzyme (ACE) inhibitor therapy after airway manipulation have been reported [1], [2], [3], [4], [5]. However, postoperative angioedema secondary to ACE inhibitor therapy has largely been overlooked by anesthesiologists. This may result in delayed recognition and unnecessary surgical airways [6]. We present a case of swelling in the tongue and oropharynx, which developed in the postanesthesia care unit (PACU). Differential diagnoses of tongue and oropharynx swelling along with appropriate therapeutic interventions are discussed.

Section snippets

Case report

A 51-year-old, 63-kg, 161-cm, African-American woman presented for an uvulopalatopharyngoplasty and bilateral tonsillectomy for obstructive sleep apnea. Her past medical history was significant for tobacco abuse, asthma, hypertension, diabetes mellitus, and gastroesophageal reflux disease. Her medications included inhaled albuterol, salmeterol, and fluticasone daily as well as lisinopril, metformin, esomeprazole, and estrogen. Her past surgical history included an uneventful hysterectomy and

Discussion

The differential diagnosis of postoperative tongue swelling includes angioedema, allergic reaction and anaphylaxis, hematoma formation, and tongue congestion secondary to traumatic or prolonged compression during surgery. Our patient's presentation was devoid of systemic symptoms, hypotension, or dermatologic manifestations seen during an allergic or anaphylactic reaction. A discrete, hard, discolored mass was not present to indicate a hematoma had formed. Tissue congestion caused by the

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