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.
Magnetic resonance image of an airway with a large lingual tonsil present and identified (arrow).
Line drawing of an LTH with the tonsillar mass filling the pre-epiglottic space and depressing the epiglottis toward the larynx.
37.2.2 How Common Is Lingual Tonsillar Hypertrophy?
Although lingual tonsillar hypertrophy or hyperplasia (LTH) was first described by Vesalius in 1543, ...