Severe macroglossia after pediatric posterior fossa tumour surgery in the prone position

Excerpt

A previously healthy nine-year-old, 26.6 kg patient whose legal guardian provided written consent for this report presented with a 4.4 × 4.7 × 5.2 cm posterior fossa tumour. There were no signs of preoperative macroglossia or predictors of difficult bag-mask ventilation or intubation. The patient underwent a midline suboccipital craniotomy in the prone position. The trachea was easily intubated with an oral endotracheal tube (ETT) via direct laryngoscopy. An oral esophageal temperature probe and a small gauze bite block were placed in the oral cavity. Intermittent mouth checks revealed no tongue pressure or biting. Following eight hr 30 min of surgery, the patient was supinated. Within 20 min, macroglossia developed and continued to worsen over the next several hours, with the ETT in situ (Figure). There were no other systemic signs or changes in ventilatory requirements. Serum tryptase, C3, and C1 esterase inhibitor concentrations were normal. There was no family history of hereditary angioedema. While remaining intubated, the patient developed tongue ulceration, methicillin-susceptible Staphylococcus aureus-related tongue infection, pseudomeningocele infection, and significant deconditioning secondary to prolonged mechanical ventilation with deep sedation. By postoperative day (POD) 12, the macroglossia had minimally improved, and the decision was made to proceed with elective tracheostomy and oral ETT removal (Figure B, C). Rapid improvement of the macroglossia ensued within 24 hr, with complete resolution by POD 16. The patient required extensive rehabilitative physiotherapy before discharge on POD 39.

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