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Table of Contents
LETTER TO EDITOR
Year : 2014  |  Volume : 30  |  Issue : 4  |  Page : 590-591

Lingual tonsillar hypertrophy: Cause of un-anticipated difficult intubation


1 Department of Anaesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Apollo Clinic, Varanasi, Uttar Pradesh, India

Date of Web Publication14-Oct-2014

Correspondence Address:
Sanjay Kumar
Type IV/68, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.142907

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How to cite this article:
Kumar S, Verma N, Agarwal A. Lingual tonsillar hypertrophy: Cause of un-anticipated difficult intubation . J Anaesthesiol Clin Pharmacol 2014;30:590-1

How to cite this URL:
Kumar S, Verma N, Agarwal A. Lingual tonsillar hypertrophy: Cause of un-anticipated difficult intubation . J Anaesthesiol Clin Pharmacol [serial online] 2014 [cited 2019 Nov 14];30:590-1. Available from: http://www.joacp.org/text.asp?2014/30/4/590/142907

Sir,

Patients with hypertrophy of lingual tonsils undergoing general anesthesia for any incidental surgery at times present as an unanticipated difficult intubation and difficult placement of laryngeal mask airway. [1] The preoperative airway assessment in these patients is essentially unremarkable. [2],[3] Fiberoptic laryngoscopy and can be used as a diagnostic modality for lingual hypertrophy cases of unanticipated failed intubation. [4] A careful history during preanesthetic workup with high index of suspicion for the existence of lingual tonsillar hypertrophy (LTH) can caution us for the likely hood of unanticipated difficult intubation and thereby help us in minimizing the associated morbidity and mortality.

Authors sought and received, written permission from the patient to report the case. A 40-year-old female patient was posted for lumpectomy of right breast. During preanesthetic evaluation, we found her a documented case of grade IV gastroesophageal reflux disease (GERD) with irregular treatment. Her general and systemic examinations were within normal limits. On examination of the airway, she had a mallampatti grade II, an inter-incisor distance of 4.5 cm, a thyro-mental distance of 6.5 cm and no artificial or loose teeth. Previous anesthesia records and indirect laryngoscopy reports showed no abnormality. Anesthesia was induced with fentanyl, midazolam and thiopentone; muscle relaxation was achieved by vecuronium bromide. Bag mask ventilation was successful with ease. Laryngoscopy with a Macintosh blade (size 3) revealed a papillary mass arising from the base of the tongue with the laryngoscopic view being grade III (Cormack Lehane classification). Repeated attempts at intubation were unsuccessful. Finally, patient was intubated with the aid of a fiberoptic bronchoscope. Her postoperative recovery and discharge from the hospital were uneventful.

Lingual tonsillar hypertrophy is commonly seen in patients with the previous history of tonsillectomy in childhood, peri-menopausal females, heavy smokers and patients suffering from GERD. [2],[3],[5] The hypertrophic lymphoid tissue at the base of the tongue may obstruct the glottic view during laryngoscopy and laryngoscopy per say may initiate bleeding from this fragile tissue mass, further aggravating the difficulty. The dynamic nature of LTH may not give us a previous history of difficult intubation, and subsequent intubations may not be difficult as well.

The review of the literature does not reveal any composite method of predicting LTH during preanesthetic evaluation. Previous studies have focused only on intraoperative methods of intubation like bougies assisted laryngoscopy, laryngeal mask airway, fiberoptic laryngoscopy, cricothyrotomy, tracheostomy and retrograde intubation to manage the unanticipated problem coming in the form of LTH rather than predicting its chances. We, therefore, suggest that a careful, detailed history during preanesthetic check-up with emphasis on previous history of tonsillectomy in childhood, peri-menopausal females, heavy smokers and patients suffering from GERD should give us a suspicion of LTH. If so then an indirect laryngoscopy prior to surgery may be helpful in diagnosing LTH and may forewarn us about the unanticipated difficult intubation.

A major limitation of our case is that we did not use laryngeal mask airway and could not retrieve pictorial views of findings on fiber - optic laryngoscopy.

 
  References Top

1.
Patel AB, Davidian E, Reebye U. Complicated airway due to unexpected lingual tonsil hypertrophy. Anesth Prog 2012;59:82-4.  Back to cited text no. 1
    
2.
Jones DH, Cohle SD. Unanticipated difficult airway secondary to lingual tonsillar hyperplasia. Anesth Analg 1993;77:1285-8.  Back to cited text no. 2
    
3.
Thiagarajan B, Arjunan K. Hypertrophied lingual tonsil an interesting case report and a review of literature. WebmedCentral ENT Scholar 2012;3:WMC003298.  Back to cited text no. 3
    
4.
Ovassapian A, Glassenberg R, Randel GI, Klock A, Mesnick PS, Klafta JM. The unexpected difficult airway and lingual tonsil hyperplasia: A case series and a review of the literature. Anesthesiology 2002;97:124-32.  Back to cited text no. 4
    
5.
Asbjørnsen H, Kuwelker M, Søfteland E. A case of unexpected difficult airway due to lingual tonsil hypertrophy. Acta Anaesthesiol Scand 2008;52:310-2.  Back to cited text no. 5
    



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