Tongue swelling and necrosis after brain tumor surgery
A 34-year-old female presented for neurosurgical evaluation with complaints of decreased left hearing and left facial numbness for the past year and a half. For the past several weeks, she noticed new difficulty with her balance.\nShe underwent audiometric testing, which revealed complete sensorineural hearing loss on the left. In addition to her left hearing loss, she had left face numbness within V1 and V2 sensory distribution. The rest of her exam was normal.\nMagnetic resonance imaging revealed a large extra-axial mass of the left cerebellopontine angle that extended to the cavernous sinus and a second lesion in the left frontal convexity. Given that the cerebellopontine mass was causing her constellation of symptoms, she was taken to the operating room for a retrosigmoid craniotomy for tumor resection.\nGeneral anesthesia was induced and her trachea was intubated uneventfully. As we have previously described, a laryngeal surface electrode (Neurovision Medical) was adhered to the endotracheal tube and placed in juxtaposition to the vocal cords to monitor evoked electromyography (EMG) in response to stimulation of cranial nerve 10. Furthermore, as previously described, a laryngeal mask airway with surface electrodes applied to its cuff[] was positioned behind the endotracheal tube so that the cuff and electrodes were abutting the posterior pharyngeal wall to record EMG in response to glossopharyngeal nerve stimulation. The mouth was then packed with gauze to ensure that neither the laryngeal mask airway (LMA), nor the electrodes shifted during the procedure and a gauze bite block was placed between the incisors and molar teeth on the left side of the mouth. Other electrodes were placed by the electrophysiological monitoring team to monitor cranial nerves 7 and 8 as well as sensory evoked potentials (SEP's) and motor evoked potentials (MEP's) and correct positioning confirmed. The patient was placed in left lateral decubitus position, park bench with right-side-up, and the head was turned to the left to facilitate retrosigmoid craniotomy. A lumbar drain was placed for brain relaxation. Brain tumor resection was performed with no apparent complications. Histopathology revealed meningioma with atypia.\nPost-operatively, she was neurologically stable and no injury to the tongue was noted on extubation. However several hours after extubation she developed significant swelling of her tongue. It had normal sensation and color but the degree of swelling prevented her from both speaking and eating. Because her airway was clear, no emergent interventions were performed. In order to help reduce her swelling and protect her airway, she was started on high-dose steroids, her head of the bed was kept up at 90° and her clinical exam was followed closely in the intensive care unit. The patient was discharged on a dysphagia diet. She was referred back to our hospital about one week later after she presented to an outside emergency room with worsening lingual pain and disfigurement of the tongue. Upon readmission, pressure necrosis was visible in the midline of the tongue presumed secondary to endotracheal tube compression due to the effect of the overlying LMA. Given the nature and extent of her of injury, otolaryngology was consulted, and concern for a possible concomitant infection was raised. Frequent nystatin oral treatments, oral steroids, and clindamycin led to improvement in the lingual edema over the next several days. Her airway remained patent. She began tolerating a clear liquid diet, and then progressed to a soft mechanical diet. She was discharged from the hospital with outpatient speech therapy.\nApproximately, 3 weeks after her initial injury, she presented to the neurosurgical clinic with a lingual pain and disfigurement. The tip of her grossly swollen tongue was bifid with a big necrotic groove extending posteriorly interfering with her speaking, eating and drinking. On exam, she had marked lingual dysarthria and the tongue itself was bifid at the tip. There was a large mass of infarcted tissue on the inferior surface. Plastic surgery was consulted and recommended operative intervention to debride and re-approximate the tongue. She was taken to the operating room where the necrotic area of the tongue was debrided. Using a Versajet machine, the mucosalized granulation tissue was removed on each side of the bifid tongue that had been split. Adjacent areas of the mucosa with the mosaic tongue patterns were then re-approximated after debriding all edges. The wound was closed primarily. At the end of the procedure, the tongue looked geographically and anatomically correct.\nTwo-week post-operatively, the tongue wound was completely healed. There was still mild swelling of the distal tongue without evidence of infection. One month after tongue repair, her tongue had totally epithelialized and her swelling had resolved. Unfortunately, she did have a cosmetic deformity of her tongue and her speech was still dysarthric. Her exam and deficits were stable, one year after tongue repair.