Fouad Ghazi Souki, MD
Shweta Rahul Yemul-Golhar, MD
Transplant Anesthesia Fellow
Yosaf Zeyed, MD
Transplant Anesthesia Fellow
Ernesto A. Pretto Jr, MD, MPH
Department of Anesthesiology
Division of Transplantation
University of Miami/Jackson Health System
The authors reported no relevant financial disclosures.
A 46-year-old woman presented for incisional hernia repair. The patient weighed 70 kg and her body mass index was 28 kg/m2. Her medical history was significant for gastroesophageal reflux disease, adenotonsillectomy, and a liver transplant. Her medications included tacrolimus, mycophenolate, amitriptyline, aspirin, lansoprazole, and gabapentin.
Preoperative airway evaluation revealed a Mallampati class II airway with normal mouth opening, neck mobility, dentition, prognathism, and a thyromental distance of 6 cm. She had a history of easy intubation with direct laryngoscopy when she presented for liver transplantation 4 years before. After placement of routine monitoring and preoxygenation, modified rapid sequence induction with cricoid pressure was performed using 50 mcg of fentanyl, 100 mg of lidocaine, 100 mg of propofol, and 50 mg of rocuronium.
Two anesthesiologists made 3 attempts at direct laryngoscopy using number 3 and 4 Macintosh blades, but failed to identify the laryngeal inlet; she had a Cormack-Lehane grade 4 view.
The patient was difficult to ventilate, but oxygen saturation remained above 90% using a 2-handed bag-mask technique with the jaw thrust maneuver and an oral airway. We decided to use a video laryngoscope, GlideScope (Verathon), and found enlarged irregular friable soft tissue that bled freely on contact. The polypoid tissue obscured the epiglottis, adhered to the base of the tongue, and extended superiorly on both sides into the pharynx. The GlideScope was gently inserted deeply and then retracted slowly against the posterior surface of the epiglottis to reveal the glottis and place the tube under vision. Images were obtained after intubation using GlideScope’s video recording function.
During her postoperative otolaryngology visit, the patient recalled having mild dysphagia, a muffled voice, and snoring. Fiber-optic nasal examination revealed moderate adenoid hypertrophy with extremely enlarged lingual tonsils that occupied the vallecula, abutted the epiglottis, and filled the pharyngeal airway, leaving only a small space posteriorly.
The patient underwent lingual tonsil coblation surgery a month later. Intubation was successful on the first attempt using a GlideScope after propofol and succinylcholine induction. Tissue pathology with detailed immunohistopathology examination and chromosome analysis demonstrated hyperplasia of lymphatic tissues without malignancy.
Lingual tonsil hypertrophy (LTH) is dynamic in nature, and more likely to present in an unanticipated manner and cause a difficult airway. Clinicians should be suspicious when dealing with patients who have active symptoms or a history suggestive of LTH. Awareness of LTH pathology, early recognition, and minimal manipulation will help prevent further deterioration of the airway.
The anesthesiologist has a very important role in communicating with the patient and surgical team regarding airway findings and referral for workup. There is no single, foolproof method for securing the LTH airway. Fiber-optic awake intubation is recommended for all patients with known LTH in need of general anesthesia. However, when faced with an unexpected difficult airway due to LTH, lack of time, and inexperience with the fiber-optic scope, video laryngoscopy—particularly the use of a GlideScope with the blade placed posterior to the epiglottis—could be a valuable aid.