Hirudotherapy in the management of post-intubation macroglossia

ABSTRACT

The medicinal use of leeches (hirudotherapy) is intimately connected to the history and practice of medicine. Here we describe a novel case of hirudotherapy in an intubated patient with macroglossia related to oral trauma and venous congestion. The patient was a 23-year-old woman with a history of morbid obesity initially admitted to an outside hospital with acute hypoxic respiratory failure secondary to COVID-19 pneumonia. She received early treatment with supplemental oxygen, dexamethasone, remdesivir, and tocilizumab but developed worsening respiratory failure requiring intubation on hospital day 13. Despite neuromuscular blockade and proning, she remained difficult to oxygenate and was transferred to our hospital 24 days after admission. Weaning of pharmacologic paralysis was complicated by ongoing ventilator dyssynchrony, and she continued to require deep sedation with multiple agents, including phenobarbital. Her respiratory status gradually improved, but weaning of sedation was marked by agitation and tongue biting. On day 50, significant isolated tongue edema was noted. Further trauma was observed on the ventral aspect of the swollen tongue where it came into contact with the teeth. High-level ventilatory support precluded tracheostomy, and conservative management with repositioning of the endotracheal tube and insertion of a bite block did not resolve the edema. The otolaryngology service was consulted, and the decision was made to trial an application of medicinal leeches. The patient received two courses of hirudotherapy with packing of the oropharynx to prevent leech migration, resulting in significant improvement of her edema. Among already mechanically ventilated patients, macroglossia remains a rare but documented complication. Endotracheal tube position and proning are the most frequently implicated etiologies. In this instance, oral trauma from tongue-biting coupled with impaired lymphovascular return from extrinsic impingement on the swollen tongue were thought to be the cause. Therapeutic options are limited and include ice, elevation, bite block placement, intravenous steroids, manual reduction and compression wrapping. In extreme cases, tracheostomy and even partial glossectomy have been performed. Hirudotherapy is well described in modern clinical practice among facial reconstructive surgeons for the management of venous congestion and resultant compromise of pedicle or microvascular tissue-free transfer flaps. Few case reports in the trauma literature have described its use with macroglossia on presentation, but its use in cases of post-intubation trauma appears novel. Given the frequent contribution of venous congestion in intubated patients with macroglossia, hirudotherapy should be considered a logical treatment modality in cases where conservative measures are unsuccessful.