Lingual tonsillar hypertrophy: Cause of un-anticipated difficult intubation.

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.[23] 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.[235] 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.