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Lingual Tonsil Hypertrophy: rescuing the airway with videolaryngoscopy
Journal of Clinical Anesthesia (2016) 35, 242–245
Case report
Lingual Tonsil Hypertrophy: rescuing the airway with videolaryngoscopy Fouad Ghazi Souki MD (Assistant Professor)a,⁎,1 , Shweta Rahul Yemul-Golhar MD (Transplant Anesthesia Fellow)b,1 , Yosaf Zeyed MD (Transplant Anesthesia Fellow)b,1 , Ernesto A. Pretto Jr MD, MPH (Professor)a,1 a
Department of Anesthesiology, Division of Transplantation, University of Miami/Jackson Health System, Miami, FL, USA Department of Anesthesiology, University of Miami/Jackson Health System, Miami, FL, USA
b
Received 26 April 2016; accepted 13 June 2016
Keywords: Lingual tonsil hypertrophy; Video laryngoscope; GlideScope
Abstract Lingual tonsils are lymphatic tissues located at the base of the tongue that may hypertrophy causing difficulty and sometimes inability to ventilate or intubate during anesthesia. Routine airway assessment fails to diagnose lingual tonsil hypertrophy. There is limited experience with use of videolaryngoscopy in cases of lingual tonsil hypertrophy. We present a case of difficult airway due to unanticipated lingual tonsil hypertrophy successfully managed by atypical video laryngoscope positioning. © 2016 Elsevier Inc. All rights reserved.
1. Introduction Lingual tonsil hypertrophy (LTH) can lead to unanticipated difficult airway during anesthesia. It is important to recognize early and institute adequate measures. Numerous case reports describe difficulties encountered with this surprising pathology along with successes and failures in securing the airway using different techniques. There is limited experience with use of videolaryngoscopy in cases of LTH. Since its advent in 2001, the video laryngoscope has proven to be a valuable tool in rescue airway management which led to its inclusion in the difficult airway algorithm [1]. We present a case of unanticipated difficult airway due to LTH successfully managed by video laryngoscope in a post–liver transplant recipient. ⁎ Correspondence: Fouad Ghazi Souki, MD, Department of Anesthesiology, Division of Transplantation, University of Miami/Jackson Health System, Miami, FL, USA. E-mail addresses: [email protected] (F.G. Souki), [email protected] (S.R. Yemul-Golhar), [email protected] (Y. Zeyed), [email protected] (E.A. Pretto). http://dx.doi.org/10.1016/j.jclinane.2016.06.007 0952-8180/© 2016 Elsevier Inc. All rights reserved.
Written informed consent for publication of this case report was obtained directly from the patient.
2. Case description A 46-year-old woman presented for incisional hernia repair. Patient's body mass index was 28 with a medical history significant for gastroesophageal reflux disease, adenotonsillectomy, and liver transplant. Her medications included tacrolimus, mycophenolate, amitriptyline, aspirin, lansoprazole, and gabapentin. Preoperative airway evaluation revealed a Mallampati class 2 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 prior. After placement of routine monitoring and preoxygenation, a modified rapid sequence induction with cricoid pressure was performed using 50 μg of fentanyl, 100 mg of lidocaine, 100 mg propofol, and 50 mg rocuronium. Three attempts at
Lingual Tonsil Hypertrophy direct laryngoscopy by 2 anesthesiologists using #3 and #4 Macintosh blades failed to identify the laryngeal inlet; she had a Cormack-Lehane grade 4 view. The patient was difficult to ventilate, but oxygen saturation remained greater than 90% using a 2-handed bag-mask technique with jaw thrust maneuver and an oral airway. Decision was made to use a GlideScope video laryngoscope, which revealed enlarged irregular friable soft tissue that bled freely upon 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 deep and then retracted slowly against the posterior surface of the epiglottis to reveal the glottis and place the tube under vision. Patient was extubated uneventfully after surgery. Postoperatively, an explanation was given to the patient regarding difficulties encountered with the airway. Given the concern for posttransplant lymphoproliferative disorder, a rare but deadly process that can present with adenotonsillar hypertrophy, patient was referred for workup and surgical excision. During postoperative otolaryngology visit, patient reported having mild dysphagia, muffled voice, and snoring. Fiberoptic nasal examination revealed moderate adenoid hypertrophy with extremely enlarged lingual tonsils which occupied the vallecula, abutted the epiglottis, and filled the pharyngeal airway leaving empty only a small amount of room posteriorly. The patient underwent lingual tonsil coblation surgery a month later. Successful intubation was achieved on the first trial using GlideScope after propofol and succinylcholine induction. Detailed immunohistopathology examination and chromosome analysis demonstrated hyperplasia of lymphatic tissues with no malignancy.
3. Discussion Unanticipated difficult intubation remains a serious problem for anesthesiologists with LTH a primary culprit. The lingual tonsils are lymphatic tissues located at the base of the tongue between the circumvallate papilla anteriorly and the epiglottis posteriorly. Lingual tonsils are fragile, not encapsulated, and bleed easily. Hypertrophied lingual tonsils have considerable variation in size ranging from few millimeters to 6 cm [2,3]. Enlarged lingual tonsils can occupy the entire vallecula, override the tip and lateral borders of the epiglottis, and displace the epiglottis posteriorly and inferiorly [2,4,5]. Lingual tonsils hypertrophy due to chronic infections, immunosuppression, gastroesophageal reflux disease, chronic allergies, and as a compensation posttonsillectomy and/or adenoidectomy [4,6]. The differential diagnosis of LTH also includes ectopic thyroid, thyroglossal duct cysts, dermoid cysts, angiomas, lymphangiomas, adenomas, fibromas, papillomas, squamous cell carcinomas, minor salivary gland tumors, and lymphomas [3]. Most conditions go unnoticed during routine preoperative evaluation because patients are mostly asymptomatic or present with vague symptoms (sore
243 throat, dysphagia, globus sensation, snoring, alteration of voice, chronic cough, dyspnea, odynophagia, and obstructive sleep apnea) [4,6]. The degree of hypertrophy of the lingual tonsil, especially in females, may play a role in the incidence of abnormal sensation of the throat [7]. LTH diagnosis can be achieved by indirect laryngoscopy, fiberoptic scope, magnetic resonance imaging, lateral neck xray, and computed tomographic scan. LTH can likewise be detected using a simple laryngeal mirror [3,8]. Prevalence of LTH in normal population is 2% to 3% [9-11]. The incidence is increased manifold in patients on immunosuppression reaching up to 10% in adults and 28% in pediatrics posttransplant [12,13].
4. Ventilation LTH can present in patients with unsuspicious, seemingly normal airway anatomy and negative airway history causing unanticipated inability to ventilate or intubate anesthetized patients [2,4,14-17] leading to a surgical airway [2,14,17,18] or death [2,18]. In a retrospective study of 33 adult patients with unanticipated failed intubation due to LTH, facemask ventilation was difficult or impossible in 35% of cases [4]. The dynamic nature and fragility of LTH mean that control of airway may change from “can” to “cannot” ventilate with repeated attempts at direct laryngoscopy [15,19-21] or laryngeal mask airway (LMA) insertion [15,20]. Ventilation difficulty may be compounded by supine patient positioning along with use of general anesthetics and neuromuscular blockade [17] that can cause pharyngeal relaxation with posterior movement of the tongue and epiglottis. Likewise, previous successful intubations do not totally exclude subsequent difficulty. Reports describe patients presenting with LTH and unexpected difficult airways having been intubated some weeks to years prior without problems [2,16,17,19].
5. Laryngeal mask airway Although the LMA is part of the standard difficult airway management algorithm and can be a life-saving tool in cannot intubate/cannot ventilate situation, it may be of limited efficacy as a supraglottic ventilatory conduit in the presence of LTH [14,17,22]. Multiple LMA insertions in presence of LTH can induce airway trauma, bleeding, and edema [17,21] making intubation more difficult [4,17,23]. Some authors reported successful airway management using the LMA with LTH [8,17,20,24,25]; others have reported inadequate or failed ventilation [14,19,26] or expressed concerns over possible inadequacy of the LMA in the presence of periglottic obstruction and bleeding [23,25,27,28]. Similarly, the ILMA and LMA-Ctrach, although anticipated to be helpful [8], have met successes and failures during
244 LTH. Goldman and Rosenblatt reported a successful CTrach intubation in an obese patient with lingual tonsillar hyperplasia, but a failed intubation with the ILMA and CTrach in the same patient several weeks later [29]. In other reports, CTrach and ILMA both failed to provide an adequate view, preventing passage of the endotracheal tube [26,30]. Matioc and Olson described the successful use of a laryngeal tube and completion of surgical procedure in a patient with LTH which could not be effectively ventilated with an LMA or intubated with laryngoscope [19].
6. Laryngoscopy blades The most common factor that limits successful tracheal intubation with LTH is inability to visualize vocal cords or lift the epiglottis during direct laryngoscopy [28]. The use of a curved (Macintosh, McCoy) blade can be a disadvantage in patients with LTH because the base of tongue is noncompliant and tip of the blade is designed to enter the vallecula with the risk of traumatic injury to the lingual tonsils and bleeding [17,31]. On the other hand, the Miller straight blade laryngoscope is preferred because its tip passes posterior and elevates the epiglottis directly. This provides better visualization of the glottis opening [32,33] with less force and reduced soft tissue compression superior to the epiglottis, favorable for difficult laryngoscopy with lesions at the base of the tongue [32]. A paraglossal laryngoscopy technique has been promoted with straight blade use [16,32]. This involves passing a straight blade laryngoscope into the right side of the mouth, advancing along the groove between tongue and palatine tonsil [ 31,32]. Some authors reported success with use of straight blade when the Macintosh laryngoscope failed in cases of LTH [34]. However, the straight blade has not always been helpful in the presence of LTH [2,17] and advocates of the straight blade admit that, if the mass is too large, it may not be possible to lift the epiglottis [32]. In an unexpected difficult intubation situation due to LTH, an ENT laryngoscope has also been recommended [17].
7. Video laryngoscope Video laryngoscope is a quick, easy-to-learn, and effective solution to unanticipated difficult airway. It is recommended by the American Society of Anesthesiologists as a first-line choice in anticipated difficult airway or as a rescue in failed direct laryngoscopy when ventilation is still possible [1]. Video laryngoscopes offer visualization of the structures of the glottis without alignment of the optical axis, and it improves the view by 1 or 2 Cormack-Lehane degrees. Video laryngoscopes are usually inserted in the midline of the mouth, and the tip advanced into the vallecula to lift
F.G. Souki et al. the epiglottis. However, the blade tip can also be passed posterior to the epiglottis to expose the glottic aperture. A J-shaped stylet is almost mandatory while intubating with video laryngoscopes to help direct the endotracheal tube toward the vocal cords. Some authors have anticipated the efficacy of videolaryngoscopy in cases of LTH [31,35,36]. Four reports described videolaryngoscopy for unanticipated difficult airway due to LTH [5,18,37,38]. In one case, the GlideScope improved Cormack-Lehane grade from 4 to 3, yet the authors were unsuccessful in intubating the patient due to poor visualization behind epiglottis and concerns about bleeding while lifting the base of the tongue [37]. In another case, Cruz et al showed that not all video laryngoscopes are the same when dealing with unexpected difficult intubation due to LTH [5]. In this report, the Airtraq failed to improve Cormack-Lehane grade 4 while looking through the view finder directly. However, the view was improved with the GlideScope, and intubation was successful with the aid of a Frova guide [5]. In other LTH reports, the Airtraq failed to improve laryngoscopy view in a 12-year-old girl with KlippelFeil syndrome [38] and a cardiac arrest patient in the emergency department [18]. In our report, GlideScope helped secure the airway without causing excess bleeding or tissue fragmentation on two occasions with the same patient. On both encounters, unanticipated and anticipated LTH the endotracheal tube was inserted easily under vision on the first attempt. The GlideScope blade was gently inserted deep and then retracted slowly to reveal the glottic opening; further retraction allowed the tip of the epiglottis to be visualized. We believe that using this approach to get the GlideScope blade posterior to the epiglottis has led to successful use with LTH. More cases are needed to validate the definitive utility of videolaryngoscopy and different types of video laryngoscopes in cases of LTH.
8. Conclusion LTH with its dynamic nature is more likely to present in an unanticipated manner and cause a difficult airway. One should be suspicious when dealing with patients who have a predictive history or active symptoms. 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 fool-proof method of securing the LTH airway. Fiberoptic 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, shortage of time, and inexperience with fiberoptic scope, videolaryngoscopy with the blade placed posterior to the epiglottis could be a valuable aid.
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References [19] [1] Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013;118:251-70. [2] Jones DH, Cohle SD. Unanticipated difficult airway secondary to lingual tonsillar hyperplasia. Anesth Analg 1993;77(6):1285-8. [3] Yamakawa PE, Andrade EH, Watanabe-Silva CH, Dos Santos Neto LL. Lingual tonsil pseudolymphoma and obstructive sleep apnea. Braz J Otorhinolaryngol 2009;75(3):469. [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. [5] Cruz P, Alarcón L, Del Castillo T, Cabrerizo P, Díaz S. Effectiveness of the GlideScope video laryngoscope in a case of unexpected difficult airway due to lingual tonsil hypertrophy. Rev Esp Anestesiol Reanim 2015; 62(5):289-92. [6] Golding-Wood DG, Whittet HB. The lingual tonsil: a neglected symptomatic structure? J Laryngol Otol 1989;103(10):922-5. [7] Iwano T, Inamura T, Tsuta Y, Hosoda Y, Ushiro K, Kumazawa T. Radiological evaluation of hypertrophy of the lingual tonsil. Zibirinsho (Jpn) 1990;83:1067-73. [8] Conacher ID, McMahon CC, Meikle D. “Chicane-like” airway as a complication of lingual tonsils (letter). Lancet 1996;348:475. [9] Sánchez-Morillo J, Gómez-Diago L, Rodríguez-Gimillo P, HerreraCollado R, Puchol-Castillo J, Mompó-Romero L. Airway evaluation by indirect laryngoscopy in patients with lingual tonsillar hypertrophy. Acta Otorrinolaringol Esp 2013;64(5):345-51. [10] Breitmeier D, Wilke N, Schulz Y, Albrecht K, Wenzel V, Kleemann WJ, et al. The lingual tonsillar hyperplasia in relation to unanticipated difficult intubation: is there any relationship between lingual tonsillar hyperplasia and tonsillectomy? Am J Forensic Med Pathol 2005;26:131-5. [11] Adachi YU, Satomoto M, Higuchi H, Watanabe K, Uchihashi Y, Satoh T. Assessment of the lingual tonsil and vallecula during fiberoptic intubation. J Anesth 2002;16:345-8. [12] Mulla O, Bajaj Y, Knight L. Severe obstructive sleep apnea due to adenotonsillar hypertrophy after liver transplantation. BMJ Case Rep 2012. [13] Ziarkiewicz-Wroblewska B, Gornicka B, Suleiman W, OldakowskaJedynak U, Wroblewski T, Bogdanska M. Posttransplant lymphoproliferative disorder: morphological picture and diagnostic difficulties. J Trans Proc 2006;38(1):168-72. [14] Fundingsland BW, Benumof JL. Difficulty using a laryngeal mask airway in a patient with lingual tonsil hyperplasia. Anesthesiology 1996; 84:1265-6. [15] Salvi L, Juliano G, Zucchetti M, Sisillo E. Hypertrophy of the lingual tonsil and difficulty in airway control. A clinical case. Minerva Anestesiol 1999;65:549-53. [16] Henderson K, Abernathy S, Bays T. Lingual tonsillar hypertrophy: the anesthesiologist's view. Anesth Analg 1994;79(4):814-5. [17] Davies S, Ananthanarayan C, Castro C. Asymptomatic lingual tonsillar hypertrophy and difficult airway management: a report of three cases. Can J Anaesth 2001;48(10):1020-4. [18] Hinoshita T, Numaguchi A, Adachi YU, Nakahara K, Matsuda N. Lingual tonsil hypertrophy diagnosed by post-mortem computed tomog-
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Case report
Lingual Tonsil Hypertrophy: rescuing the airway with videolaryngoscopy Fouad Ghazi Souki MD (Assistant Professor)a,⁎,1 , Shweta Rahul Yemul-Golhar MD (Transplant Anesthesia Fellow)b,1 , Yosaf Zeyed MD (Transplant Anesthesia Fellow)b,1 , Ernesto A. Pretto Jr MD, MPH (Professor)a,1 a
Department of Anesthesiology, Division of Transplantation, University of Miami/Jackson Health System, Miami, FL, USA Department of Anesthesiology, University of Miami/Jackson Health System, Miami, FL, USA
b
Received 26 April 2016; accepted 13 June 2016
Keywords: Lingual tonsil hypertrophy; Video laryngoscope; GlideScope
Abstract Lingual tonsils are lymphatic tissues located at the base of the tongue that may hypertrophy causing difficulty and sometimes inability to ventilate or intubate during anesthesia. Routine airway assessment fails to diagnose lingual tonsil hypertrophy. There is limited experience with use of videolaryngoscopy in cases of lingual tonsil hypertrophy. We present a case of difficult airway due to unanticipated lingual tonsil hypertrophy successfully managed by atypical video laryngoscope positioning. © 2016 Elsevier Inc. All rights reserved.
1. Introduction Lingual tonsil hypertrophy (LTH) can lead to unanticipated difficult airway during anesthesia. It is important to recognize early and institute adequate measures. Numerous case reports describe difficulties encountered with this surprising pathology along with successes and failures in securing the airway using different techniques. There is limited experience with use of videolaryngoscopy in cases of LTH. Since its advent in 2001, the video laryngoscope has proven to be a valuable tool in rescue airway management which led to its inclusion in the difficult airway algorithm [1]. We present a case of unanticipated difficult airway due to LTH successfully managed by video laryngoscope in a post–liver transplant recipient. ⁎ Correspondence: Fouad Ghazi Souki, MD, Department of Anesthesiology, Division of Transplantation, University of Miami/Jackson Health System, Miami, FL, USA. E-mail addresses: [email protected] (F.G. Souki), [email protected] (S.R. Yemul-Golhar), [email protected] (Y. Zeyed), [email protected] (E.A. Pretto). http://dx.doi.org/10.1016/j.jclinane.2016.06.007 0952-8180/© 2016 Elsevier Inc. All rights reserved.
Written informed consent for publication of this case report was obtained directly from the patient.
2. Case description A 46-year-old woman presented for incisional hernia repair. Patient's body mass index was 28 with a medical history significant for gastroesophageal reflux disease, adenotonsillectomy, and liver transplant. Her medications included tacrolimus, mycophenolate, amitriptyline, aspirin, lansoprazole, and gabapentin. Preoperative airway evaluation revealed a Mallampati class 2 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 prior. After placement of routine monitoring and preoxygenation, a modified rapid sequence induction with cricoid pressure was performed using 50 μg of fentanyl, 100 mg of lidocaine, 100 mg propofol, and 50 mg rocuronium. Three attempts at
Lingual Tonsil Hypertrophy direct laryngoscopy by 2 anesthesiologists using #3 and #4 Macintosh blades failed to identify the laryngeal inlet; she had a Cormack-Lehane grade 4 view. The patient was difficult to ventilate, but oxygen saturation remained greater than 90% using a 2-handed bag-mask technique with jaw thrust maneuver and an oral airway. Decision was made to use a GlideScope video laryngoscope, which revealed enlarged irregular friable soft tissue that bled freely upon 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 deep and then retracted slowly against the posterior surface of the epiglottis to reveal the glottis and place the tube under vision. Patient was extubated uneventfully after surgery. Postoperatively, an explanation was given to the patient regarding difficulties encountered with the airway. Given the concern for posttransplant lymphoproliferative disorder, a rare but deadly process that can present with adenotonsillar hypertrophy, patient was referred for workup and surgical excision. During postoperative otolaryngology visit, patient reported having mild dysphagia, muffled voice, and snoring. Fiberoptic nasal examination revealed moderate adenoid hypertrophy with extremely enlarged lingual tonsils which occupied the vallecula, abutted the epiglottis, and filled the pharyngeal airway leaving empty only a small amount of room posteriorly. The patient underwent lingual tonsil coblation surgery a month later. Successful intubation was achieved on the first trial using GlideScope after propofol and succinylcholine induction. Detailed immunohistopathology examination and chromosome analysis demonstrated hyperplasia of lymphatic tissues with no malignancy.
3. Discussion Unanticipated difficult intubation remains a serious problem for anesthesiologists with LTH a primary culprit. The lingual tonsils are lymphatic tissues located at the base of the tongue between the circumvallate papilla anteriorly and the epiglottis posteriorly. Lingual tonsils are fragile, not encapsulated, and bleed easily. Hypertrophied lingual tonsils have considerable variation in size ranging from few millimeters to 6 cm [2,3]. Enlarged lingual tonsils can occupy the entire vallecula, override the tip and lateral borders of the epiglottis, and displace the epiglottis posteriorly and inferiorly [2,4,5]. Lingual tonsils hypertrophy due to chronic infections, immunosuppression, gastroesophageal reflux disease, chronic allergies, and as a compensation posttonsillectomy and/or adenoidectomy [4,6]. The differential diagnosis of LTH also includes ectopic thyroid, thyroglossal duct cysts, dermoid cysts, angiomas, lymphangiomas, adenomas, fibromas, papillomas, squamous cell carcinomas, minor salivary gland tumors, and lymphomas [3]. Most conditions go unnoticed during routine preoperative evaluation because patients are mostly asymptomatic or present with vague symptoms (sore
243 throat, dysphagia, globus sensation, snoring, alteration of voice, chronic cough, dyspnea, odynophagia, and obstructive sleep apnea) [4,6]. The degree of hypertrophy of the lingual tonsil, especially in females, may play a role in the incidence of abnormal sensation of the throat [7]. LTH diagnosis can be achieved by indirect laryngoscopy, fiberoptic scope, magnetic resonance imaging, lateral neck xray, and computed tomographic scan. LTH can likewise be detected using a simple laryngeal mirror [3,8]. Prevalence of LTH in normal population is 2% to 3% [9-11]. The incidence is increased manifold in patients on immunosuppression reaching up to 10% in adults and 28% in pediatrics posttransplant [12,13].
4. Ventilation LTH can present in patients with unsuspicious, seemingly normal airway anatomy and negative airway history causing unanticipated inability to ventilate or intubate anesthetized patients [2,4,14-17] leading to a surgical airway [2,14,17,18] or death [2,18]. In a retrospective study of 33 adult patients with unanticipated failed intubation due to LTH, facemask ventilation was difficult or impossible in 35% of cases [4]. The dynamic nature and fragility of LTH mean that control of airway may change from “can” to “cannot” ventilate with repeated attempts at direct laryngoscopy [15,19-21] or laryngeal mask airway (LMA) insertion [15,20]. Ventilation difficulty may be compounded by supine patient positioning along with use of general anesthetics and neuromuscular blockade [17] that can cause pharyngeal relaxation with posterior movement of the tongue and epiglottis. Likewise, previous successful intubations do not totally exclude subsequent difficulty. Reports describe patients presenting with LTH and unexpected difficult airways having been intubated some weeks to years prior without problems [2,16,17,19].
5. Laryngeal mask airway Although the LMA is part of the standard difficult airway management algorithm and can be a life-saving tool in cannot intubate/cannot ventilate situation, it may be of limited efficacy as a supraglottic ventilatory conduit in the presence of LTH [14,17,22]. Multiple LMA insertions in presence of LTH can induce airway trauma, bleeding, and edema [17,21] making intubation more difficult [4,17,23]. Some authors reported successful airway management using the LMA with LTH [8,17,20,24,25]; others have reported inadequate or failed ventilation [14,19,26] or expressed concerns over possible inadequacy of the LMA in the presence of periglottic obstruction and bleeding [23,25,27,28]. Similarly, the ILMA and LMA-Ctrach, although anticipated to be helpful [8], have met successes and failures during
244 LTH. Goldman and Rosenblatt reported a successful CTrach intubation in an obese patient with lingual tonsillar hyperplasia, but a failed intubation with the ILMA and CTrach in the same patient several weeks later [29]. In other reports, CTrach and ILMA both failed to provide an adequate view, preventing passage of the endotracheal tube [26,30]. Matioc and Olson described the successful use of a laryngeal tube and completion of surgical procedure in a patient with LTH which could not be effectively ventilated with an LMA or intubated with laryngoscope [19].
6. Laryngoscopy blades The most common factor that limits successful tracheal intubation with LTH is inability to visualize vocal cords or lift the epiglottis during direct laryngoscopy [28]. The use of a curved (Macintosh, McCoy) blade can be a disadvantage in patients with LTH because the base of tongue is noncompliant and tip of the blade is designed to enter the vallecula with the risk of traumatic injury to the lingual tonsils and bleeding [17,31]. On the other hand, the Miller straight blade laryngoscope is preferred because its tip passes posterior and elevates the epiglottis directly. This provides better visualization of the glottis opening [32,33] with less force and reduced soft tissue compression superior to the epiglottis, favorable for difficult laryngoscopy with lesions at the base of the tongue [32]. A paraglossal laryngoscopy technique has been promoted with straight blade use [16,32]. This involves passing a straight blade laryngoscope into the right side of the mouth, advancing along the groove between tongue and palatine tonsil [ 31,32]. Some authors reported success with use of straight blade when the Macintosh laryngoscope failed in cases of LTH [34]. However, the straight blade has not always been helpful in the presence of LTH [2,17] and advocates of the straight blade admit that, if the mass is too large, it may not be possible to lift the epiglottis [32]. In an unexpected difficult intubation situation due to LTH, an ENT laryngoscope has also been recommended [17].
7. Video laryngoscope Video laryngoscope is a quick, easy-to-learn, and effective solution to unanticipated difficult airway. It is recommended by the American Society of Anesthesiologists as a first-line choice in anticipated difficult airway or as a rescue in failed direct laryngoscopy when ventilation is still possible [1]. Video laryngoscopes offer visualization of the structures of the glottis without alignment of the optical axis, and it improves the view by 1 or 2 Cormack-Lehane degrees. Video laryngoscopes are usually inserted in the midline of the mouth, and the tip advanced into the vallecula to lift
F.G. Souki et al. the epiglottis. However, the blade tip can also be passed posterior to the epiglottis to expose the glottic aperture. A J-shaped stylet is almost mandatory while intubating with video laryngoscopes to help direct the endotracheal tube toward the vocal cords. Some authors have anticipated the efficacy of videolaryngoscopy in cases of LTH [31,35,36]. Four reports described videolaryngoscopy for unanticipated difficult airway due to LTH [5,18,37,38]. In one case, the GlideScope improved Cormack-Lehane grade from 4 to 3, yet the authors were unsuccessful in intubating the patient due to poor visualization behind epiglottis and concerns about bleeding while lifting the base of the tongue [37]. In another case, Cruz et al showed that not all video laryngoscopes are the same when dealing with unexpected difficult intubation due to LTH [5]. In this report, the Airtraq failed to improve Cormack-Lehane grade 4 while looking through the view finder directly. However, the view was improved with the GlideScope, and intubation was successful with the aid of a Frova guide [5]. In other LTH reports, the Airtraq failed to improve laryngoscopy view in a 12-year-old girl with KlippelFeil syndrome [38] and a cardiac arrest patient in the emergency department [18]. In our report, GlideScope helped secure the airway without causing excess bleeding or tissue fragmentation on two occasions with the same patient. On both encounters, unanticipated and anticipated LTH the endotracheal tube was inserted easily under vision on the first attempt. The GlideScope blade was gently inserted deep and then retracted slowly to reveal the glottic opening; further retraction allowed the tip of the epiglottis to be visualized. We believe that using this approach to get the GlideScope blade posterior to the epiglottis has led to successful use with LTH. More cases are needed to validate the definitive utility of videolaryngoscopy and different types of video laryngoscopes in cases of LTH.
8. Conclusion LTH with its dynamic nature is more likely to present in an unanticipated manner and cause a difficult airway. One should be suspicious when dealing with patients who have a predictive history or active symptoms. 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 fool-proof method of securing the LTH airway. Fiberoptic 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, shortage of time, and inexperience with fiberoptic scope, videolaryngoscopy with the blade placed posterior to the epiglottis could be a valuable aid.
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