B53-04 The Tongue That Took the Airway: A Case of Severe Macroglossia

Abstract Introduction Severe macroglossia is a rare but serious manifestation of hypothyroidism, occasionally associated with myxedema coma. While hypothyroidism is common, tongue swelling remains under-recognized and can lead to airway obstruction and nutritional compromise. The true incidence of macroglossia in myxedema coma is unclear, which may delay diagnosis and management. Case Presentation A 55-year-old woman with chronic kidney disease, hypertension, hyperlipidemia, and hypothyroidism presented with lethargy and altered mental status. She was disheveled, lethargic, and found to have marked tongue and neck swelling. Laboratory testing revealed a TSH of 117 consistent with severe hypothyroidism.She was intubated for airway protection and started on IV levothyroxine, stress-dose steroids, and broad-spectrum antibiotics. Imaging of the head, neck, and maxillofacial region showed no abscess, thyroiditis, or hematoma. Despite appropriate thyroid and steroid therapy, her macroglossia persisted. Two additional steroid trials provided minimal benefit. She developed secondary adrenal insufficiency confirmed by ACTH testing, requiring continued hydrocortisone therapy.Persistent macroglossia necessitated tracheostomy and PEG placement on hospital days 12 and 14. Over the following weeks, gradual improvement in tongue swelling allowed decannulation on hospital day 35. She was discharged in stable condition after full recovery of thyroid function. Discussion Macroglossia secondary to myxedema coma is rarely reported and represents a potentially life-threatening airway complication. Accumulation of mucopolysaccharides within the tongue and soft tissues leads to edema that resolves only with sustained thyroid hormone replacement. In our patient, corticosteroids had minimal effect, and improvement occurred slowly over several weeks despite adequate hormonal therapy.This case underscores the importance of early airway protection, multidisciplinary management, and clinical patience in allowing thyroid replacement therapy to reverse tissue infiltration. Awareness of this presentation may prevent unnecessary surgical interventions, such as glossectomy, when medical management can achieve gradual resolution. Conclusion Severe macroglossia in myxedema coma is an underrecognized but reversible cause of airway obstruction. Early thyroid hormone replacement, airway stabilization, and careful monitoring can lead to full recovery and avoid invasive procedures. This abstract is funded by: N/A