Life-Threatening Macroglossia after Posterior Fossa Surgery: A Surgical Positioning Problem

Case Report: A large (32 mm) right-sided vestibular schwannoma was resected totally by retrosigmoid approach in a 55-year-old female patient. The patient was intubated orally and positioned in left lateral park bench position using the Mayfield skull clamp: semi to three-fourth prone lateral position, right shoulder rotated anteriorly, neck flexion and rotation. Gauzes were placed orally to prevent pressure necrosis of the tongue. After extubation, immediate and progressive obstruction of breathing was observed. Oral inspection revealed macroglossia and reintubation was indicated because of respiratory distress. Intravenous corticosteroids, antihistamines, and tranexamic acid failed to arrest progressive swelling. Upper airway abscesses were excluded. Tracheostomy was performed after 2 weeks resulting in a volume decrease within 24 hours. The patient was discharged in good clinical condition 48 days after surgery with normal facial function (HB grade I). Oral feeding was adequate for liquid and semisolid food, but restricted for solid food. Tongue strength measurements showed decreased values for maximum isometric power, recovering completely after 7 months. The patient continues to feel slight swelling and limitation. Conclusion: Macroglossia as a postoperative complication should be kept in mind in posterior fossa surgery since it can be life-threatening. We hypothesize impediment of lymphatic and venous drainage of the tongue due to prolonged compression.