A case of difficult airway due to lingual tonsillar hypertrophy in a patient with Down's syndrome

In this report, we describe airway management of symptomatic lingual tonsillar hypertrophy in a pediatric patient with Down's syndrome. Besides obstructive sleep apnea, the history included a small atrial septal defect with mild aortic regurgitation and Moyamoya disease. Anesthesia was induced with IV administration of 1 mg/kg of propofol, followed by inhalation of sevoflurane in 100% oxygen. Muscle relaxants were not used on induction. Rigid laryngoscopy could not visualize the epiglottis because of hypertrophied tonsillar tissue, and mask ventilation became difficult when spontaneous breathing stopped. We avoided using a laryngeal mask airway because of a slight bleeding tendency presumably caused by preoperative antiplatelet therapy. Fiberoptic bronchoscopy through the nasal cavity in combination with jet ventilation successfully identified the glottis and allowed nasotracheal intubation to be accomplished. After lingual tonsillectomy, the patient was extubated on the seventh postoperative day, after supraglottic edema had resolved. Fiberoptic nasotracheal intubation under inhaled anesthesia may therefore be preferable in pediatric or uncooperative patients with symptomatic lingual tonsillar hypertrophy.     

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.     

Successful fiberoptic intubation for a patient with lingual tonsillar hyperplasia

Hypertrophied lingual tonsils are rare, but may cause difficulty or inability in tracheal intubation during induction of general anesthesia. A 39-yr-old woman was scheduled for resection of symptomatic hypertrophied lingual tonsils. In this patient, we examined two methods of oro-tracheal intubation either with rigid laryngoscopy or flexible fiberoscopy using trans-nasal fiberopic monitoring. Direct laryngoscopy failed to expose the trachea because of large hypertrophied tissue, and fiberoscopic intubation was also difficult since a large mass hindered acquiring a suitable view. However, transnasal fiberoscopic monitoring could guide the orotracheal fiber into the trachea for intubation. When an anesthesiologist can predict the abnormality of lingual tonsils, this combination might be recommended for difficult airway and intubation.     

Complicated airway due to unexpected lingual tonsil hypertrophy

We report an unexpected failed laryngeal mask airway in a patient with unrecognized lingual tonsil hypertrophy (LTH). A 19-year-old obese woman presented for extraction of multiple teeth via intravenous general anesthesia. Surgery was interrupted due to a laryngospasm midway through the procedure. The laryngospasm required the existing laryngeal mask airway to be removed so the patient could be suctioned. Although it is unclear the extent of obstruction caused by LTH, the surgery had to be postponed due to the discovery of enlarged lingual tonsils, which prevented endotracheal intubation. One reason for unexpected difficult airways is attributed to LTH. It is recognized that LTH is more common in patients with obstructive sleep apnea; however, LTH also has an increased prevalence in obese children with prior palatine tonsillectomies or adenoidectomies. Unexpected LTH can complicate general anesthesia by making placement of a laryngeal mask airway difficult. Thus, further research needs to be conducted to gain a deeper understanding on how to reduce the risks presented by LTH during sedation surgeries.     

Tracheal intubation for two patients with lingual tonsil hyperplasia and prospect of difficult airway management

Lingual tonsil hyperplasia is rare, but may cause difficult or inpossible tracheal intubation. We experienced two cases of tracheal intubation for lingual tonsil hyperplasia. A 71-yr-old man was scheduled for resection and biopsy of symptomatic hypertrophied lingual tonsils. In this patient, we performed oro-tracheal intubation by rigid laryngoscopy from left oral angle, because left hypertrophied lingual tonsils are smaller than those on the right side. A 44-yr-old man was scheduled for resection of symptomatic hypertrophied lingual tonsils after lingual tonsillitis. In this patient, we performed nasotracheal intubation using fiberoptic bronchoscopy with assist of jaw-lift and tongue-extension. When an anesthesiologist can predict the abnormality of lingual tonsils, these methods might be recommended for difficult airway and intubation. However, it is necessary to prepare a difficult airway management set including laryngeal mask airway, intubating laryngeal mask airway, fiberoptic bronchos-copy and transcutaneous tracheotomy set. And most important is preliminary evaluation of airway and cautious planning of tracheal intubation.     

Unexpected difficult intubation due to lingual tonsillar hyperplasia in a thoracotomy patient: intubation with the double-lumen tube using stylet and fiberoptic bronchoscopy

Lingual tonsillar hyperplasia is rare, and it may cause difficulty with tracheal intubation during induction of general anesthesia. A different orotracheal intubation technique was performed using a double-lumen endotracheal tube, flexible fiberoptic bronchoscope, and a stylet, in an unexpected difficult endobronchial intubation case due to massive lingual tonsillar hyperplasia.     

A case of unexpected difficult airway due to lingual tonsil hypertrophy

Clinical value of preoperative bedside screening tests for predicting difficult airway remains limited. Asymptomatic lingual tonsil hypertrophy is a known cause of unexpected difficult airway. We report a case as a reminder of this.     

Difficult airway due to protruding macroglossia in a child with lymphangioma

Lymphangiomas, or cystic hygromas, are relatively uncommon congenital malformations of the lymphatic system that usually present during the first years of childhood. They are rare in adults. A search of the literature on MedLine revealed only few reports about lymphangioma as a cause of difficult airway management after the neonatal period. Herein, we present a case of difficult intubation due to protruding macroglossia in a 5-year-old girl diagnosed with recurrent lesions of lymphangioma. We also discuss possible problems in airway protection, drug choice, and post-operative follow-up associated with surgical excision of these lesions.     

Difficult airway in a pediatric patient with Klippel-Feil syndrome and an unexpected lingual tonsil

Klippel-Feil Syndrome (KFS) is a congenital defect characterized by the fusion of at least two cervical vertebrae. This article presents the case of a 12-year-old girl with KFS planned for scoliosis surgery. A short, rigid neck and limited mouth opening were predictors of difficult airway access. After failing multiple intubation attempts employing several devices, the case was postponed. Imaging tests showed lingual tonsil hypertrophy and a deviation of the tracheal axis, clarifying the causes of the failed intubation and suggesting new approaches for airway management. As far as we know, the association of KFS and lingual tonsil hypertrophy has not been reported before in the literature.