Asymptomatic lingual tonsillar hypertrophy and difficult airway management: a report of three cases

PURPOSE: To report on the airway management of three cases of asymptomatic lingual tonsillar hypertrophy (LTH). MATERIAL: On three separate occasions, patients presenting for elective surgery were subsequently found to have asymptomatic LTH. In all cases preoperative airway examination was essentially unremarkable and no unusual difficulties were anticipated. In the first case, despite an inability to visualize the glottic opening, the patient was intubated successfully on the initial attempt and had no further problems in the perioperative period. In the second case, neither direct laryngoscopy, utilizing the MacIntosh and McCoy blades, nor fibreoptic visualization enabled successful intubation. Ventilation was maintained with a laryngeal mask airway (LMA) until the anesthetic was reversible. Upon awakening and removal of the LMA, the patient totally obstructed and could not be ventilated, necessitating emergency cricothyroidotomy. The third patient was an elderly gentleman in whom successful intubation was eventually achieved, with considerable difficulty, by the otorhinolaryngologist (ENT surgeon) utilizing a straight blade. On a second occasion, he was again intubated by the same ENT surgeon, this time utilizing the anterior commissure blade. All three patients were subsequently discharged without further sequelae. CONCLUSION: Asymptomatic LTH can cause varying degrees of unexpected difficulty in securing the airway and, at present, no single method will necessarily improve the chances of successful intubation. Therefore, strategies to manage unanticipated difficult intubation secondary to supraglottic airway pathology need to be performed and practiced, including the establishment of a transtracheal airway.