Tongue Necrosis and Cleft after Prolonged Transesophageal Echocardiography Probe Placement

Tongue injury is a relatively uncommon complication in the perioperative period. It is usually attributed to prolonged orotracheal intubation. Here, we report a case of necrosis of the tongue resulting in a permanent cleft that occurred after prolonged cardiac surgery during which a transesophageal echocardiography probe was placed for monitoring.

A 61-yr-old Asian Indian man was scheduled to undergo elective mitral, aortic, and tricuspid valve replacement surgery. Significant medical history included mitral valve replacement 8 yr previously for rheumatic heart disease, congestive heart failure, chronic atrial fibrillation, diabetes mellitus, and hypothyroidism. Medications included aspirin (discontinued 8 days before surgery), warfarin (stopped 2 days before surgery and replaced by low-molecular-weight heparin), digoxin, glipizide, and levothyroxine. The results of routine investigations were normal.

In the operating room, the patient was intubated atraumatically on the first attempt using a 7.5-mm-ID endotracheal tube, and the tube was taped at 24 cm at the level of the teeth. Anesthesia was maintained with isoflurane–narcotic technique. The transesophageal echocardiography probe (6-T multiplane transesophageal transducer; GE Healthcare, Milwaukee, WI) was placed atraumatically. Cardiopulmonary bypass was initiated and maintained without complications. An initial attempt to wean off bypass was unsuccessful because of bleeding and oozing. After the coagulopathy was corrected, weaning was successful after a total of 315 min cardiopulmonary bypass time. The patient was subsequently transferred to the surgical intensive care unit on standard dose ranges of multiple pressors (epinephrine, vasopressin, dobutamine) and placed on a ventilator. Total surgery and anesthesia times were 549 and 650 min, respectively.

Swelling of the tongue was noticed immediately on admission to the surgical intensive care unit, and it was not associated with concomitant facial or neck edema. A midline partial necrosis of the tongue became apparent on postoperative day 2. Notably, the midline position of the tongue injury was away from the endotracheal tube, which was positioned at the right lateral side of the tongue and was taped to the right side of the mouth. Planned tracheostomy was postponed because of severe adult respiratory distress syndrome, coagulopathy, and hemodynamic instability that required multiple inotropic and vasopressor support. Multiple bedside tongue débridements and routine oral care did not improve the patient’s condition. Tracheostomy was performed on postoperative day 18, and local care of the tongue continued with marked improvement. A photograph taken 10 days after tracheostomy is shown (fig. 1).

The patient was then transferred to a long-term care facility with the tracheostomy in place. Six months later, the tongue had healed with a residual median linear cleft. The trachea was subsequently decannulated. This resulted in a significant improvement in articulation, and the patient recovered with only a minor functional deficit.

Tongue injury is an infrequent but potentially severe complication of prolonged orotracheal intubation. It has been reported from the use of endotracheal tubes, laryngeal mask airways, and esophageal–tracheal Combitubes.1 

The pathophysiologic mechanisms of the injury include prolonged glossal compression with venous congestion, edema, and ischemia that lead to the tongue necrosis.2The main reason for the swelling seems to be a compression of the glossal blood vessels, especially the lingual veins. Other causes include sublingual hematoma3and obstruction of the submandibular duct.4The position of the patient may also contribute to this problem. Massive tongue edema after spinal surgery has been reported, attributed to the flexed thoracic–cervical position required.5Lingual nerve injury has been associated with orotracheal intubation and may contribute to this problem because of sensory deprivation.6 

Yamamoto et al.  7reported a case of edema of the tongue after intraoperative monitoring by a transesophageal probe, and in this report, the tongue returned to normal size 1 day after surgery. In our patient, prolonged (540 min) contact with the transesophageal echocardiography probe might have contributed to edema that progressed to necrosis. The natural prominence at the base of the tongue and midline position of the probe favor this explanation as being the likely cause of the injury. It is unlikely that midline tongue injury could have been caused by endotracheal tube placement, because it was positioned more laterally in the mouth.

When edema of the tongue is noted during or after general anesthesia, an attempt should be made to change the position of the endotracheal tube or other transoral devices. These simple maneuvers may prevent progression to tissue necrosis. When actual necrosis is noted, early débridement is indicated.8If prolonged ventilatory support is anticipated, tracheostomy should be performed as soon as possible to facilitate aggressive tongue and oral care. The formation of a tongue cleft is a permanent impairment that may result in residual functional deficit.9 

*Stroger Hospital of Cook County, Chicago, Illinois. ksriram41@hotmail.com