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More on lingual tonsillar hypertrophy

Ottawa, Ontario

To the Editor:

Davies et al. reported their experience with three patients with lingual tonsillar hypertrophy.¹ We recently managed a similar case. A diabetic 57-yr-old female presented for axillo-femoral bypass; she refused regional anesthesia. Following induction of general anesthesia, an obstructing soft tissue mass at the base of the tongue was observed on direct laryngoscopy and tracheal intubation was impossible with both laryngoscopy and with a lighted-stylet. Adequate ventilation was achieved with a size 3 laryngeal mask. Following this event, naso-laryngoscopy revealed lingual tonsillar hypertrophy, with the mass occupying and filling the valleculae and obstructing the view of the epiglottis. Because she derived no symptoms from the lesion, surgical excision was not felt to be indicated.

When re-scheduled for surgery, she again refused regional anesthesia but agreed to awake tracheal intubation. She received glycopyrrolate 0.6 mg sc, supplemental oxygen by nasal prongs, incremental sedation and topical anesthesia of the airway. A Bullard laryngoscope fitted with oxygen tubing (8 L•min^-1), a dedicated stylet with a size 7 endotracheal tube, and a surgical camera were introduced into the airway. Under video guidance the laryngoscope was passed to the base of the tongue and used to gently elevate the tonsil, allowing the laryngoscope to move beyond and into the laryngeal inlet, visualizing the vocal cords. The trachea was intubated and the procedure proceeded uneventfully.

We agree with Davies that these patients test the limits of our airway management technologies. These lesions are asymptomatic and often unanticipated. They are not readily compressible and may not permit direct viewing of the laryngeal inlet. In one patient, Davies noted the use of an anterior commissure blade, an instrument unfamiliar to most anesthesiologists. However, the more commonly available Bullard laryngoscope is possibly the ideal instrument, both in the anticipated and unanticipated scenario. In the scenario of an airway mass, the Bullard can be fitted with a camera, allowing for visualization of the entire intervention. Its robust construction permits gentle manipulation of airway tissues, allowing it to create the necessary endoscopic airspace. Because it carries the tracheal tube mounted on it, no second working channel is needed for tube placement - an obvious advantage in the patient with a lingual tonsil and a relatively non-compliant airway.

We agree that no single technique or technology can be guaranteed to resolve all airway issues; strategies to manage unanticipated difficult ventilation and intubation must be preformulated and rehearsed. Consideration should also be given to the routine placement of an oxygenation stylet before extubation of the trachea in these patients.

Reference

1 Davies S, Ananthanarayan C, Castro C. Asymptomatic lingual tonsillar hypertrophy and difficult airway management: a report of three cases. Can J Anesth 2001; 48: 1020–4.[Abstract/Free Full Text]

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