Objectives: (1) Present a unique case of partial necrosis of the dorsal tongue caused by an endotracheal tube; (2) highlight the importance of verifying proper endotracheal tube positioning during cases requiring prolonged intubation. Methods: Case report and literature review. Results: A 50 year-old man underwent total thyroidectomy and bilateral ymphadenectomies for papillary thyroid carcinoma. A nerve monitoring endotracheal tube was used during the case. Postoperatively, the patient reported tongue pain and examination revealed partial necrosis of his dorsal tongue. On follow up, the patient had improved tongue pain and well-healing dorsal tongue. Discussion: We present the a case of tongue ischemia and partial necrosis due to oral endotracheal intubation, specifically with a nerve monitoring endotracheal tube, which has not previously been reported in the English literature. Tongue necrosis due to compression by an endotracheal tube during prolonged intubation is unusual, however surgeons, anesthesiologists and those involved in the care of intubated patients should consider the potential for this complication when orienting and securing endotracheal tubes. Conclusions: This unique case of tongue necrosis underscores the importance of proper endotracheal tube positioning during prolonged intubation.
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