Chapter 37. Airway Management of a Patient with an Unanticipated Difficult Laryngoscopy (Lingual Tonsillar Hypertrophy)

An obese, diabetic 57-year-old woman presented for femorotibial bypass with vein and graft. Despite a recommendation in favor, she refused regional anesthesia. A general anesthetic with endotracheal intubation due to the prolonged nature of the operation was planned. Following induction of general anesthesia, bag-mask-ventilation (BMV) was difficult and an immediate attempt at direct laryngoscopy was made. An obstructing soft tissue mass in the vallecula at the base of the tongue was observed with the direct laryngoscope; tracheal intubation was impossible with both direct laryngoscopy and with a lighted stylet and some bleeding was observed after several attempts at intubation. A size 3 laryngeal mask airway (LMA) was placed, adequate ventilation was achieved, the procedure was abandoned, and the patient was awakened and taken to the recovery room. Following the procedure, the patient was referred to an otolaryngologist, and nasolaryngoscopy revealed lingual tonsillar hypertrophy (LTH). The lingual tonsil was observed to be occupying and filling the vallecula and obstructing the view of both the epiglottis and the laryngeal inlet. Because she derived no symptoms from the lesion, surgical excision was not felt to be indicated and she was referred back to her vascular surgeon.

In the patient described, LTH completely obstructed the view of the larynx and access to the airway.

37.2.1 What Are Lingual Tonsils?

The lingual tonsils are components of Waldeyer throat ring and consist of lymphoid tissue located in the posterior third of the tongue which can extend into the vallecula. Waldeyer throat ring is completed by the adenoids and the palatine tonsils. Unlike the palatine tonsils, there is no definite capsule for lingual tonsils. They are inconsistent in their presence and are most typically absent in adults. When present, they lie on either side of the median epiglottic fold, may be both variable and asymmetric in size, and can become very large (Figures 37-1 and 37-2). The natural history of lingua tonsils is not well delineated; periodic growth and regression is likely. In a manner similar to the palatine tonsils, they may become inflamed and, when swollen (as in lingual tonsillitis), the mass may fill the vallecula and press the epiglottis down toward the glottis, causing variable degrees of airway compromise. They are not readily compressible and may not permit direct viewing of the laryngeal inlet with a direct laryngoscope during the course of conventional airway management.

37.2.2 How Common Is Lingual Tonsillar Hypertrophy?

Although lingual tonsillar hypertrophy or hyperplasia (LTH) was first described by Vesalius in 1543, its prevalence and relevance to clinical practice remains ill-defined.1 Reports of airway difficulties in patients with LTH are infrequent but recurrent suggesting that patients with the condition are regularly but not commonly encountered and recognized by anesthesiologists. Whether or not LTH would always be recognized as being present and being the underlying cause of airway difficulties is a relevant question. Goldman and Greenland reported separately of two patients in whom airway difficulties were encountered by experienced anesthesiologists.2,3 Postoperative assessments with video and MRI, respectively, revealed the presence of LTH which was suspected in neither case during the initial interventions.

Breitmeier et al conducted an assessment of 497 autopsy specimens to determine the incidence of LTH in an unselected population.4 In 16 specimens (3.2%) large lingual tonsils were detected. Of the 16 specimens with LTH, 10 had normal palatine tonsils and the others had either no palatine tonsil or remnants only. Adachi et al performed fiberoptic evaluation and tracheal intubation in 105 elective adult surgical patients to determine the incidence of LTH.5 Thirty-four patients (32%) had small lingual tonsils and seven patients (7%) had large lingual tonsils identified; there was no lingual tonsil identified in 64 (61%) patients. The correlation between the presence of a lingual tonsil and difficult intubation with a direct laryngoscope was not evaluated by these authors. Guimaraes et al evaluated the airways of 71 obese children between the ages of 13 and 21 using computed tomography to determine the frequency of LTH.6 Forty-four (62%) of the subjects had LTH, which is greater than the frequency previously reported in both normal subjects and those with obstructive sleep apnea. Ten of the children had very large lingual tonsils. Children with previous palatine tonsillectomy had a higher prevalence of measurable lingual tonsils and large lingual tonsils compared with those who still had their palatine tonsils.

Lingual tonsils are likely more prevalent than past reports would indicate, but are still relatively uncommon and probably impact on airway care infrequently. This is because even when present, they are usually small in size. It is probable that they would present difficulties either when they become very large or combine with other factors to make airway management difficult.

37.3.1 What Patient Characteristics Are Associated with LTH?

There are no large-scale studies of populations of patients which would allow for an accurate evaluation of the etiologic and associated characteristics in patients with LTH. The literature suggests that the presence of LTH may be associated with obesity, sleep apnea, and previous palatine tonsillectomy.1,4,6 The strength of the associations is not quantifiable and the majority of patients with these associated conditions do not have LTH. The patient described in the case was obese and, although she may have had an increased relative risk for LTH, she would have been considered to be at relatively low absolute risk due to the low population prevalence.

37.3.2 What Symptoms Occur in Patients with LTH?

Clinical symptoms of LTH are not present in all patients with the condition and, in fact, seem absent in many, even in some who present with very large lingual tonsils. Symptoms which do occur may be subtle and are neither sensitive nor specific. Some patients report a sensation of fullness or discomfort in the throat, rarely to the extreme of dysphagia.7 When they are inflamed, sore throat may be present. But, without knowing the presence of LTH, it is likely that the symptoms of lingual tonsillitis would often be ascribed to those of a common viral pharyngitis (simple sore throat). Very large lingual tonsils may cause obstructive sleep apnea or upper airway obstruction, but may also be associated with either mild or no symptoms.1,8,9 Acute and complete airway obstruction as a result of inflamed lingual tonsils has been reported leading to sudden death.10

The patient described in the case reported no symptoms attributable to LTH and was surprised to be presented with the diagnosis. Her husband reported that she was a noisy nocturnal breather, but neither she nor her husband described any signs or symptoms suggestive of obstructive sleep apnea.

37.3.3 Is LTH Detectable with Preoperative Airway Assessment?

Most patients with characteristics associated with LTH do not have the condition and many patients who actually have LTH, including those with very large tonsils, do not have symptoms. LTH is not detectable on routine preoperative physical examination or airway assessment. It is detectable with diagnostic imaging modalities such as plain x-ray, computed tomography, and magnetic resonance imaging as well as with upper airway endoscopy. Subjecting all patients with characteristics associated with LTH to more detailed preoperative airway assessments is difficult to defend from the perspective of both evidence base and resource utilization. However, because of the association between LTH and obstructive sleep apnea (OSA), consideration should be given to diagnostic imaging or nasopharyngoscopy to rule out LTH as an underlying cause in patients newly diagnosed with OSA.

The index patient described in the case had a reassuring airway examination and would not have been considered at risk for either difficult ventilation or intubation with a conventional airway assessment. There was no indication to subject her to a more rigorous airway evaluation based on the history and airway assessment.

37.4.1 What Are the Implications of LTH for Anesthesiologists?

The presence of LTH has been associated with difficult airway management following the induction of anesthesia, and in most of the published reports, LTH seems to be either the only factor responsible for the difficulties with airway management, or the most important one. In many instances, the patients were asymptomatic, had a normal preoperative airway evaluation, and the difficulties were unanticipated. In the largest series published in the anesthesia literature, that of Ovassapian et al, none of the 33 patients reviewed retrospectively had an airway examination that suggested an increased potential for difficult laryngoscopy or intubation.11 However, unanticipated difficulties were experienced with either or both bag-mask-ventilation and direct laryngoscopy in all of them. The lungs of 12 patients were difficult to ventilate by bag and mask. In five cases, failed intubation occurred but there were no details as to the number of attempts at direct laryngoscopy; in one case two failed attempts were made; in nine cases three failed attempts were recorded; in 14 cases four failed attempts occurred; in three cases, there were five attempts; and in one case, six attempts were made before the procedure was abandoned. The tracheas of six patients were subsequently intubated using a fiberoptic bronchoscope (FOB) with the patient awake; four of these interventions were characterized as moderately difficult and two as easy. Of the remaining 27 patients who subsequently underwent FOB-assisted tracheal intubation, 4 interventions were deemed difficult, 12 were moderately difficult, and 11 were reported as easy. Difficulty was experienced passing the endotracheal tube over the FOB and into the trachea in 11 patients. All 33 patients were subsequently evaluated using fiberoptic pharyngoscopy to determine possible causes of the failure; the only finding common to all 33 patients was the presence of LTH.

Other authors have reported similar findings with either single cases or smaller series. But the themes are consistent with the report of Ovassapian et al; unanticipated difficulties were often encountered with ventilation of the lungs and intubation of the trachea.9,12,13 These difficulties with ventilation were not always or easily overcome with the use of laryngeal mask airways nor were difficulties with tracheal intubation routinely or readily overcome with the use of adjuncts or alternatives to the direct laryngoscope. Difficulties seem common even in situations where difficulties were anticipated and experienced anesthesiologists deployed advanced alternatives for airway management. It is fortunately the case that, in many of the reports, it was possible for the anesthesiologist to maintain sufficient oxygenation through a variety of interventions to safely abandon further attempts at intubation and awaken the patient. However, Jones and Cohle reported a death due to failed airway management in a 24-year-old patient presenting with probable appendicitis.14 Following induction of anesthesia, bag-mask-ventilation was impossible and tracheal intubation failed despite repeated attempts with both a direct laryngoscope and a fiberoptic bronchoscope. A tracheotomy was performed but the patient never regained consciousness and died 8 hours postoperatively. At autopsy, a large lingual tonsil was discovered.

In the patient described in the case, moderate difficulties were experienced with bag-mask-ventilation although it was possible to maintain her oxygen saturation in a clinically acceptable range. However tracheal intubation was unsuccessful with both direct laryngoscopy and with a lighted stylet. Because of the difficulties with ventilation, a decision was made to attempt placement of a laryngeal mask airway, which was successful and resulted in an effective airway.

37.4.2 How Do Lingual Tonsils Interfere with Bag-Mask-Ventilation and Direct Laryngoscopy?

If the lingual tonsils are large enough, the airway is obstructed at the base of the tongue and elevation of the tongue may be inadequate to relieve the obstruction. Placement of an oral airway may result in the distal aperture of the airway being directly opposed by the tonsillar mass and obstructed as well. It is possible that a nasal airway may better bypass the obstruction caused by LTH than an oral airway, but this is by no means certain. In the patient described in the case, an oral airway did not seem to reduce the difficulties with bag-mask-ventilation and no attempt was made to place a nasal airway.

Successful laryngoscopy is dependent on the development of a line-of-sight from the eye to the larynx. Most difficulties with direct laryngoscopy can be grouped into a limited number of categories: mouth opening is inadequate to admit the blade adequately; airway angles are sharp and irreducible; soft tissues are either overabundant and compromising or noncompliant and unyielding; there are obstructing masses present; or blood and secretions interfere with light reflection. Horton et al demonstrated the importance during laryngoscopy of control of the hyoid bone with the tip of the laryngoscope blade reporting that the body of the hyoid was drawn forward and tilted downward.15 This tip placement resulted in tensioning of the hyoepiglottic ligament, elevation of the epiglottis, and exposure of the laryngeal structures. Tripathi and Pandey similarly reported that placement of the tip of a curved Macintosh blade in the pre-epiglottic space (vallecula) proximal to the hyoid bone achieved elevation and tilting of the hyoid bone, tensioning of the hyoepiglottic ligaments, and an optimal glottic view.16 The presence of the LTH at the base of the tongue, in the pre-epiglottic space, will prevent proper placement of the laryngoscope blade thus interfering with the basic mechanisms of laryngoscopy. The obstruction of the airway lumen by the LTH is the second factor that will interfere with the direct laryngoscopy.

The presence of the lingual tonsil may completely obstruct the line-of-sight necessary for successful laryngoscopy. Many of the alternatives to the direct laryngoscope, such as the indirect fiberoptic and video-optic laryngoscopes, also depend on the development of a line-of-sight from the instrument tip and this requirement may render them ineffective for the task of airway salvage if direct laryngoscopy proves to be impossible due to LTH. The use of blind techniques, such as the lightwand, in the presence of a known soft tissue mass in the airway is controversial and some would consider such techniques to be contraindicated due to the risk of tissue trauma and bleeding.

37.4.3 What Airway Management Practices Have Been Employed in Patients with LTH?

In the majority of reports, airway management difficulties were unanticipated and included both difficult or failed ventilation and intubation. The use of laryngeal mask airways is a common feature in the reports; the outcomes of LMA deployments ranged across the spectrum from successful ventilation and intubation using the LMA as a conduit for tracheal intubation, to no improvement in ventilation and continued failed intubation. With respect to difficulties encountered with intubation, in those scenarios that were unanticipated, the most common response was persistent attempt at direct laryngoscopy without success. The use of flexible bronchoscopes, Eschmann tracheal introducers (bougies) and intubation catheters, straight blades, and an anterior commissure blade by an otolaryngologist have all been reported with variable results.

The most common technology reported as being deployed in anticipated difficult situations (interventions made subsequent to the diagnosis of LTH being made) has been the flexible bronchoscope (FB), typically in an awake patient. Although usually successful, difficulties with both accessing the airway with the FB and subsequently with advancing the endotracheal tube into the trachea are common. These difficulties likely result not only from the obstruction of the airway lumen by the LTH but also from the requirement to pass deep to the LTH with the FB along the posterior pharyngeal wall, then to turn sharply in the opposite direction to access the laryngeal inlet, and finally to turn one more time to pass into the tracheal lumen. The turning radius of the FB is likely an issue when multiple turns have to be executed over a short distance.

The Bullard laryngoscope was employed in this case as it was thought that it would be capable of lifting the epiglottis and the tonsil to allow access to the laryngeal inlet. By performing the laryngoscopy in an awake patient, it was presumed that if a laryngeal view could not be obtained, the procedure could be safely abandoned and an alternative technique attempted.

37.4.4 What Is the Role of Extraglottic Airways in the Management of LTH?

The most commonly deployed extraglottic airway reportedly being used has been the laryngeal mask airway (LMA), in one form or another. These have been placed to facilitate both ventilation and intubation with varying results. In some reports, difficult ventilation was improved after the placement of the LMA, but intubation through the device was not possible.9,13,17 In other reports, placement of an LMA resulted in both a resolution of difficult ventilation and provided a conduit for successful tracheal intubation.2,18 Finally, some authors report little apparent improvement in difficult ventilation after placement of an LMA and failed attempts at intubation using the LMA as a conduit.12,19 The success of the LMA in reducing the severity of difficult ventilation and providing an intubation conduit in the setting of LTH is likely impacted both by the size of the tonsil, the position of the LMA orifice in relation to the laryngeal inlet, and the degree of airway obstruction resulting from the tonsillar hypertrophy. In most reports, placement of an LMA has resulted in some reduction in the ventilation difficulties being encountered. The available reports support a recommendation that placement of an LMA be considered early if difficulty with ventilation is being experienced in the setting of an LTH. Whether a smaller than usual LMA may provide equal or greater benefit in this setting is speculative.

A laryngeal mask airway was placed easily in the case described and resulted in a much improved airway. A size 3 LMA was used, although it would have been conventional local practice to use a size 4 in this patient.

37.4.5 Which of the Available Airway Technologies Should Be Most Effective in the Setting of LTH?

There are two anatomic issues relevant to airway management which must be considered in a patient with LTH. The first issue is the angles to be negotiated between the mouth and the glottic inlet and the second is the degree of obstruction of the airway lumen by the tonsil. As discussed, if the tonsils are very large, then to either access the laryngeal inlet or obtain a view of the larynx, the airway instrument must pass deep to the base of the tongue and behind the tonsil along the posterior pharyngeal wall. To get a view of the larynx, it must then move sharply anteriorly and away from the posterior pharyngeal wall to develop the line-of-sight. To access the laryngeal inlet it also must pass anteriorly and over the posterior commissure, and then turn once again to move down through the cords, and into the tracheal lumen. If the instrument is dependent for its success on the development of a line-of-sight from its tip to the laryngeal inlet from a point in the airway above the larynx, this line-of-sight is likely to be obstructed by the presence of large tonsils.

A rigid device such as the Bullard™ laryngoscope (BL) is possibly the ideal instrument for the management of the airway in a patient with LTH, both in the anticipated and unanticipated scenario.18,20 It is capable of negotiating the angles described and its robust construction permits gentle manipulation of airway tissues, allowing it to create the necessary endoscopic airspace. It may be used to gently elevate the lingual tonsil to reduce the degree of obstruction and, when placed in its final position, the tip of the BL rests beyond the lingual tonsil in the laryngeal inlet, bypassing the lumenal obstruction caused by the tonsil. Although the BL does require a line-of-sight from blade tip to target, typically the blade tip should be placed beyond the tonsil when positioned. Because it can carry the tracheal tube mounted on its dedicated stylet, no second working channel is needed for tube placement—an obvious advantage in the patient with a lingual tonsil and a relatively noncompliant airway. As well, in the scenario of an airway mass, the BL can be fitted with a standard surgical camera, allowing for visualization of the entire intervention and reducing the potential for trauma to the tonsil. Despite the theoretic advantages of an instrument, such as the BL for the management of the airway in a patient with LTH, it would be imprudent to conclude that it would always be effective.

The FB may also be used to successfully negotiate the angles described and is also capable of bypassing the obstructed lumen. Whereas a rigid instrument may be used to elevate tissues and reduce the angles which must be negotiated, the FB must negotiate them as it finds them. It may be very difficult to traverse the airway due to the repeated turns which must be executed over a relatively short distance. As well, it may be difficult to avoid soiling the bronchoscope on the tonsil or cause bleeding by contacting the tonsil if there is a high degree of obstruction of the lumen. Finally, passing the tube over the FB may prove difficult as well as the tube must negotiate the same angles previously negotiated by the FB. Warming the endotracheal tube and the use of a Parker-type tube and ensuring a close match between tube and FB diameters may all increase the likelihood of successful tube passage. As well, combining a rigid blade with the FB and using the blade to elevate the soft tissues to permit passage of the FB may be an effective salvage strategy.

Ultimately, it may not be possible to secure the airway from a supraglottic approach and either a retrograde or an infraglottic surgical approach may be necessary. A wire inserted through a cricothyroid membrane puncture could be used to facilitate either a retrograde intubation or to guide a supraglottic technique (eg, threading an FB loaded with an endotracheal tube). Cricothyrotomy or tracheotomy may be performed either electively or urgently if a "cannot intubate-cannot ventilate" situation is encountered.

As previously noted, and for the reasons already outlined, awake tracheal intubation was attempted with a Bullard™ laryngoscope. The Bullard™ blade was placed under the epiglottis and used to gently elevate both the epiglottis and the tonsil affording a full view of the larynx. Intubation of the trachea was readily achieved using a tube mounted on the dedicated stylet.

37.4.6 How Should the Algorithms of Chapter 2 Be Applied to the Care of the Patient with LTH?

If LTH is recognized before the induction of anesthesia, the airway assessment would be considered non-reassuring and concerns would be raised regarding both bag-mask-ventilation and tracheal intubation. Given that assessment, management would be directed by Panel A of the ASA Difficult Airway Management Algorithm in Figures 2-1 and 2-2, or the Emergency Difficult Airway Algorithm in Figure 2-5 and an awake intubation would be recommended; consideration should also be given to a surgical airway in some instances. If LTH was unanticipated and difficulties are experienced with ventilation and/or intubation, management would be directed by Panel B of the ASA Difficult Airway Management Algorithm in Figures 2-1 and 2-2 or the Failed Airway Algorithm in Figure 2-6.

37.4.7 What Is Optimal Elective Airway Management in a Patient Known to Have LTH?

Although bag-mask-ventilation has usually been possible in situations where LTH was unanticipated and encountered, both difficult and failed ventilation have been reported. As well, difficult and failed intubation using either direct laryngoscopy, and adjuncts and alternatives to the direct laryngoscope are common. It is the author's opinion that the airway assessment in a patient known to have LTH is non-reassuring with respect to both bag-mask-ventilation and tracheal intubation and an awake intubation is both the most prudent and optimal approach to airway management as dictated by the ASA Difficult Airway Management Algorithm (Figure 2-2).

37.5.1 How Was This Patient Managed?

When rescheduled for surgery, she again refused regional anesthesia but agreed to awake tracheal intubation. Preoperatively, she received glycopyrrolate 0.6 mg subcutaneously to dry oral-pharyngeal secretions. She was provided with supplemental oxygen by nasal prongs, incremental sedation, and topical anesthesia of the airway. A Bullard™ laryngoscope (BL) fitted with oxygen tubing (8 L·min−1), a dedicated stylet with a 7.0 mm ID 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 lingual tonsil, allowing the laryngoscope to move beyond and into the laryngeal inlet, whereupon the vocal cords were visualized. The trachea was intubated and the surgery then proceeded uneventfully. At the end of the procedure, the patient was allowed to awaken and once fully and cognitively responsive, her trachea was extubated. She was observed in a high-surveillance nursing unit overnight and then discharged to a ward bed.

37.5.2 Are There Special Considerations for Tracheal Extubation in Patients with LTH?

It may be impossible to reestablish an airway in a patient with LTH following extubation of the trachea. The combination of the residual effects of the anesthetics, the anatomic sequela of the airway interventions, and the stress of managing a lost airway, superimposed on the preexistent pathology will likely combine to create the nightmare airway experience. Extubation of the trachea in a patient with LTH should only occur when there is clear evidence that the anesthetic effects are fully reversed, and that the patient is awake and cognitively responsive. The management of tracheal extubation in a patient with LTH would be directed by Figure 2-7, the Difficult Airway Extubation Algorithm and consideration should also be given to the routine placement of an airway exchange catheter before extubation of the trachea in these patients. As well, the anesthesia practitioner must have made preparations for a surgical airway if extubation leads to loss of the airway and it cannot be immediately reestablished.

37.6.1 Do Other Conditions Similar to LTH Occur with Airway Implications?

Laryngeal, epiglottic, and vallecular cysts have been cited in case reports as having been associated with both difficult and failed ventilation and intubation.21-23 They are relatively common and usually small but may become very large; most are asymptomatic with symptoms becoming more common as they become larger. Very large cysts may cause dysphagia and occasionally symptoms of airway obstruction. About half originate from the epiglottis and most of these are found on the lingual surface of the epiglottis.24,25 In adults, they are presumed to largely originate from obstructed ducts of submucosal glands with eventual dilation of the glands causing a retention cyst. As they increase in size, they may fill the vallecula and distort the epiglottis in a manner similar to that of lingual tonsils (Figure 37-3). They may occur at any age although they seem most common in the fifth and sixth decades. Routine preoperative airway evaluation is unlikely to reveal the presence of the cyst in the absence of symptoms. If suspicions are present, multiple diagnostic imaging modalities may be used to identify large cysts and nasolaryngoscopy is also useful. In many of the available reports, difficulties with bag-mask-ventilation were not encountered. However, difficult ventilation is more likely to be a potential issue with very large cysts and failed ventilation and death has been reported at induction of anesthesia. Aspiration of the cysts to facilitate airway management has also been reported by a number of authors and has been successful in reducing the degree of obstruction caused by the cyst.26 If large cysts have been identified on preoperative assessments, they should be more fully evaluated using diagnostic imaging and airway endoscopy to assess their size and the degree of airway compromise. Aspiration of very large cysts before the induction of anesthesia has been reported.27 An awake intubation is probably the most prudent course of care.

37.6.2 What Information Should Be Provided to the Patient Once LTH Is Diagnosed?

The patient should be informed of the presence and implications of LTH and airway cysts and be provided with a difficult airway letter for future practitioners, stating the findings and recommendations. It has been our practice to refer these patients to an otolaryngologist for follow-up although management has been typically conservative in patients with asymptomatic lesions. Lingual tonsillectomy and excision, marsupialization, or de-roofing of cysts may be considered if the lesions are symptomatic.

LTH is a relatively uncommon disorder in adults defined by overgrowth of lymphoid tissues at the base of the tongue and in the vallecula. Most lingual tonsils, even if enlarged, are small enough so as to not interfere with airway management. But some may be so large as to completely obstruct access to the airway and be life threatening. LTH may be associated with obesity, sleep apnea, and previous palatine tonsillectomy, but the majority of patients with these conditions do not have LTH. Symptoms are not common, although, if present, are obstructive in nature and some patients provide histories of sleep apnea. Routine preoperative airway assessment is not likely to reveal the presence of underlying LTH, although imaging modalities such as radiography, computed tomography, and magnetic resonance imaging and endoscopy are all effective evaluation and diagnostic strategies. If significant LTH is recognized preinduction, consideration should be given to awake intubation. The flexible bronchoscope has been the most frequently described and the most effective technique for managing such patients. If LTH is not recognized preinduction, difficult or failed ventilation and laryngoscopy/intubation may be experienced. Varying success has been reported with the use of extraglottic devices to improve ventilation. If difficult laryngoscopy is experienced, persistent efforts at laryngoscopy are not likely to be successful. Early consideration should be given to salvage attempts with the flexible bronchoscope, rigid fiberoptic devices, subglottic airways, or abandonment of the anesthetic if that can be safely achieved. Patients who are newly diagnosed with LTH should be counseled as to its implications and offered consultation with an otolaryngologist.