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An Interesting Case of Lingual Necrosis

Roman Rahmani, Justin Stafford

University of New England College of Osteopathic Medicine


Necrosis of the tongue due to mechanical endotracheal tube (ETT) intubation is an uncommon finding, but under certain conditions such as cardiogenic shock coupled with trauma, ischemia can be present resulting in tongue skeletal muscle cell death. Cardiogenic shock resulting in hypotension and decreased organ perfusion can be detrimental, especially leading to end-organ hypoperfusion and damage. We present a case of cardiogenic shock, acute kidney injury, hypotension, and eventual necrosis of the tongue that was exacerbated by prolonged ETT intubation. The prolonged intubation and ETT intubation caused hypoperfusion to the lingual tissue. Previous studies have shown that tongue necrosis with cardiogenic shock and prolonged ETT intubation have had increased rates of mortality. This case also helps support that necrosis of the tongue due to ETT intubation with cardiogenic shock could be a signifier of poor prognosis in patients. This patient was a 76 year old African American female who after an uncomplicated total knee arthroplasty went into cardiopulmonary arrest during a physical therapy session. Due to cardiopulmonary arrest the patient was intubated and was maintained on vasopressors being intubated for a total of 17 days. On the last day of extubation the patient was noticed to have a pale and necrotic looking portion of their tongue. The patient had a tracheostomy procedure performed the following day with approximately one-third of her tongue found to be necrotic. This case add to the small body of literature discussing the complications of extended endotracheal intubation in the setting of vascular instability. We are hypothesizing that due to mechanical trauma from the intubation and inability for the patient to maintain appropriate blood pressure that this combination could have lead to lingual necrosis. We also postulate the idea that because the tongue is well vascularized structure from bilateral lingual arteries, which is one reason that endotracheal intubation rarely results in necrosis, that the necrosis signifies poor prognosis due to several instances of patients in other studies who passed away all who had been intubated and had resultant lingual necrosis. This is one of very few cases within the last 20 years with such an outcome.

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