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Fiberoptic intubation in a child with previous unexpected difficult airway due to lingual tonsil hypertrophy
Rev Esp Anestesiol Reanim. 2019;66(9):478---482
Revista Española de Anestesiología y Reanimación www.elsevier.es/redar
CASE REPORT
Fiberoptic intubation in a child with previous unexpected difficult airway due to lingual tonsil hypertrophy夽 J. Sarmento Castro a,∗ , C.C. Costa a,b , H. Pereira a,c , R. Oliveira a , P. Santos a,c a
Anesthesiology Department, Centro Hospitalar São João, Porto, Portugal Anesthesiology Department, Centro Hospitalar Entre Douro e Vouga, Santa Maria da Feira, Portugal c Faculdade de Medicina da Universidade do Porto, Porto, Portugal b
Received 10 January 2019; accepted 4 March 2019 Available online 8 November 2019
KEYWORDS Airway management; Lingual tonsil hypertrophy; Fiberoptic intubation; Paediatric anaesthesia
PALABRAS CLAVE Manejo de la vía aérea; Hipertrofia de amígdala lingual;
Abstract Lingual tonsils are normal components of the oropharynx localized at the base of the tongue, which sometimes can become enlarged by inflammation. This may be a cause of unexpected difficult airway, considering most patients are asymptomatic and this supraglottic mass is not usually detected during a routine preoperative airway assessment. Commonly described in adults, there are limited reports in paediatric patients. We describe a case of a 12 years old boy diagnosed with a cerebellar brain tumour that was scheduled for a resection. The first surgery was postponed because of respiratory complications as a result of unexpected difficult airway due to lingual tonsil hypertrophy. His surgery was rescheduled and a plan for airway management was laid out: fibroscopic intubation with spontaneous ventilation. Considering this is a problem that cannot be identified by regular airway examination, we should be aware of the most effective ways to manage the situation as it arises. © 2019 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
Intubación con fibra óptica en un ni˜ no con dificultad de la vía no prevista previamente, debido a hipertrofia de amígdala lingual Resumen Las amígdalas linguales son componentes normales de la orofaringe, situadas en la base de la lengua, que a veces pueden agrandarse debido a inflamación. Esto puede ser causa de vía aérea difícil no prevista, considerando que muchos pacientes son asintomáticos
夽
Please cite this article as: Sarmento Castro J, Costa CC, Pereira H, Oliveira R, Santos P. Intubación con fibra óptica en un ni˜ no con dificultad de la vía no prevista previamente, debido a hipertrofia de amígdala lingual. Rev Esp Anestesiol Reanimac. 2019;66:478---482. ∗ Corresponding author. E-mail address: [email protected] (J. Sarmento Castro). 2341-1929/© 2019 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
Fiberoptic intubation in a child with lingual tonsil hypertrophy
Intubación con fibra óptica; Anestesia pediátrica
479
y que esta masa supra-glótica no es detectada habitualmente durante la valoración rutinaria preoperatoria de la vía aérea. Se describe de manera común en adultos, pero existen pocos informes sobre pacientes pediátricos. Describimos el caso de un ni˜ no de 12 a˜ nos, con diagnóstico de tumor cerebral cerebeloso, programado para resección quirúrgica. La primera cirugía se pospuso debido a complicaciones respiratorias como resultado de vía aérea difícil a causa de hipertrofia de la amígdala lingual. Se reprogramó la cirugía, estableciéndose un plan para el tratamiento de la vía aérea: intubación con fibra óptica con ventilación espontánea. Considerando que se trata de un problema que no puede identificarse mediante una exploración regular de la vía aérea, debemos tomar conciencia acerca de los modos más efectivos de manejar esta situación, cuando surja. © 2019 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Publicado por Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction Lingual tonsils are normal components of Waldeyer’s ring, consisting of small size lymphatic tissue, normally located at the base of the tongue.1,2 Enlargement of these structures, due to inflammation or hypertrophy, has been recognized as a possible cause of unexpected difficult airway and associated with negative outcomes.3,4 Lingual tonsil hypertrophy (LTH) may be asymptomatic and is usually not detected by a routine preoperative airway assessment. Commonly described in adults, there are limited reports regarding airway management difficulties caused by LTH in children. The degree of LTH can be assessed by the LTH grading scale,5 which ranges from 1 (minimal) to 4 (severe). We report a case of a child in which fiberoptic intubation was successfully achieved after previous unexpected difficult intubation due to a grade 4 LTH.
Case report A 12 year-old boy was scheduled for cerebellar pilocytic astrocytoma resection following a surgical intervention 4 years prior. Medical history included asthma and an adenotonsillectomy at the age of 2. No difficulty in ventilation or orotracheal intubation was observed in his previous anaesthesias. Airway assessment revealed mild retrognathia, normal mouth opening with welldefined visualization of oropharyngeal structures, tongue of normal size, Mallampati I, no limitations in neck mobility, and normal thyromental and sternomental distances. After induction of general anaesthesia (GA) with propofol (60 mg), fentanyl (0.15 mg) and rocuronium (40 mg), laryngoscopy was performed with a #3 Macintosh blade, showing a significant friable mass of lymphoid-like tissue arising from the base of the tongue and occupying the vallecula, with right predominance, corresponding to a grade 3 Cormack-Lehane view. Two attempts at blind intubation were unsuccessful and, after two further attempts by an
experienced paediatric anaesthesiologist using a #3 Macintosh blade and a frova intubating introducer, orotracheal intubation was finally achieved with a 6 mm reinforced cuffed endotracheal tube. The patient remained stable, but traumatic bleeding was detected during intubation attempts. He was immediately examined in the operating room by an otolaryngologist, who performed haemostatic control and took a specimen from the lesion. However, due to ventilation difficulties, surgery was postponed. The patient was extubated 4 days after surgery due to significant laryngeal oedema. Intubation was uneventful. Biopsy was interpreted as lingual tonsil hypertrophy, which was visible after reassessing previous cranial magnetic resonance imaging (MRI) (Fig. 1). This imaging study was not performed under anaesthesia. After reviewing the medical history, the patient’s parents indicated that he snored at night, but had no obstructive sleep apnoea. Surgery was rescheduled for 2 two months later. After explaining the procedure, the parents consented to fiberoptic intubation. In case of intubation failure, an otolaryngology team was available to perform a surgical airway. Prior to induction, adrenaline (1 mg) and dexamethasone (8 mg) spray was administered. Anaesthesia was induced with sevoflurane (4---8%; MAC < 1.6) in 100% O2 , maintaining spontaneous ventilation. Oral fiberoptic intubation was attempted with a 3.6 mm Karl Storz® fiberoptic bronchoscope, and initial airway visualization showed diffuse polypoid tissue extended from the base of the tongue to the midline of the vallecula and lingual aspect of the epiglottis, obscuring clear vision of the epiglottis and concealing the glottic opening (Fig. 2A---C). The vocal cords surrounding the tissues presented with significant symmetrical diffuse oedema (Fig. 2D). The cords were sprayed with 6 mL of 2% lidocaine and tracheal intubation was successfully achieved with a 6.5 mm reinforced cuffed tube with no signs of traumatic bleeding. The patient remained stable, and O2 saturation remained above 93%. Surgery was performed in the prone position and lasted for 3 h with no complications.
480
J. Sarmento Castro et al.
Figure 1
Preoperative cranial sagittal T1 weighted images, showing laryngeal obstruction caused by LTH (white arrows).
Figure 2 Initial airway fiberoptic view showing extensive enlargement of lingual tonsils, covering the vallecula and epiglottis borders with no visualization of the cords (A and B). Fiberoptic bronchoscope advancement showing significant swelling of the epiglottis (C) and tissue surrounding vocal cords (D).
After surgery, the patient was admitted to the paediatric ICU and was successfully extubated 24 h later in the presence of the attending paediatrician and otolaryngologist. He was discharged 1 week later with no complications.
Discussion LTH is a relatively frequent condition with an estimated prevalence of 2---3.2%.1,6 The aetiology is unknown, but
gastric reflux, obesity, chronic infections and history of tonsillectomy, as seen in this case, have been suggested.7 Two thirds of patients with LTH have a history of palatine tonsillectomy or adenoidectomy,7 and may be due to a compensatory mechanism after surgery in patients with repeated pharyngeal inflammatory episodes.4 Lingual tonsils are anatomically limited by the circumvallate papilla anteriorly and the epiglottis posteriorly,
Fiberoptic intubation in a child with lingual tonsil hypertrophy surrounding the entrance of the upper airway. Depending on their size, hypertrophied lingual tonsils can occupy the entire vallecula, override the tip and lateral borders of the epiglottis and displace this structure posteroinferiorly,3,4,7 causing difficult mask ventilation and tracheal intubation.4 Neuromuscular block may worsen laryngoscopy view by abolishing muscle support for the upper airway, and allowing posterior movement of the tongue and epiglottis. These difficulties can progress to a ‘‘cannot ventilate, cannot intubate’’ situation, which may result in the patient’s death.3 Nevertheless, it is difficult to anticipate complications arising from LTH, because most patients are asymptomatic and supraglottic masses are not detectable on a routine preoperative airway assessment. Our patient had a normal airway evaluation and difficult intubation was not anticipated. In a study of 33 patients with previous unexpected difficult intubation, Ovossapian et al.4 observed that LTH was the only common feature. However, airway examination was normal in all cases. Another important factor, as shown in our case, is that a history of previous successful intubations does not exclude subsequent difficulties in airway management.3 Consequently, LTH may only be detected preoperatively by fiberoptic laryngoscopy (FL) and indirect mirror laryngoscopy (IL).6 MRI, lateral neck X-ray, and computed tomographic scan are also important tools for the anaesthesiologist to identify supra-glottic masses.1 In our case, the first unexpected difficult intubation could have been anticipated if preoperative cranial MRI had been carefully evaluated. Therefore, the preoperative anaesthesia evaluation should include an analysis of previous imaging studies, in order to detect potential airway management problems. Nevertheless, despite risk factors for LTH, CT and MRI should not be routinely performed in all children because of radiation exposure, cost, limited availability, and the possible need for GA, respectively. FL and IL can be a safe and effective option in collaborative paediatric patients. Additionally, when the otolaryngologist detects LTH and recommends a procedure under GA, this information should be transmitted to the anaesthesiology team. Lingual tonsils are surrounded by a poorly organized capsule which makes them more vulnerable to trauma during continuous intubation attempts. Moreover, lingual tonsils and the supraglottic larynx share similar lymphatic drainage, allowing contiguous spread of oedema to the epiglottis.7 This may explain the generalized oedema we found during fiberoptic laryngoscopy. Considering the difficulties encountered in the first approach to this patient, we decided to perform oral fiberoptic intubation (FOI) in order to avoid airway swelling and bleeding. FOI is widely accepted as a valuable technique in the management of difficult airway, and is the gold standard for patients with known LTH.4 Difficult airway management in children with LTH is limited to a few cases reports. In one case, tracheal intubation was achieved by circumventing the supraglottic polypoid tissue using a straight blade.8 However, Go˜ ni-Zaballa et al.2 described failed intubation
481 despite the use of multiple devices. Tracheal intubation was only achieved after FOI guided by 3D CT scan imaging. In contrast to our case, this patient had significant predictors of difficult airway related to Klippel-Feil syndrome. Additional cases of LTH also required the use of FOI to successfully secure the airway.9,10 LTH continues to be an important cause of unanticipated difficult airway, because most patients are asymptomatic, and physical examination or previous medical history are not reliable predictors of complications. An understanding of the characteristics of LTH and early detection of this condition can prompt the anaesthesiologist to minimize airway manipulation in order to avoid negative outcomes. Although there is no perfect technique to secure the airway in these patients, FOI is recognized as the least traumatic and most likely to be effective. For these reasons, it should be the first option for anaesthesiologist experienced in the use of fiberoptic laryngoscopy. Finally, if all non-invasive techniques fail, anaesthesiologists should be familiar with invasive airway management.
Declaration of Competing Interest The authors declare that they have no conflict of interests
References 1. Sanchez-Morillo J, Gomez-Diago L, Rodriguez-Gimillo P, Herrera-Collado R, Puchol-Castillo J, Mompo-Romero L. Airway evaluation by indirect laryngoscopy in patients with lingual tonsillar hypertrophy [Article in English, Spanish]. Acta Otorrinolaringol Esp. 2013;64:345---51. 2. Go˜ ni-Zaballa M, Perez-Ferrer A, Charco-Mora P. Difficult airway in a pediatric patient with Klippel-Feil syndrome and an unexpected lingual tonsil. Minerva Anestesiol. 2012; 78:254---7. 3. Jones DH, Cohle SD. Unanticipated difficult airway secondary to lingual tonsillar hyperplasia. Anesth Analg. 1993;77: 1285---8. 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. Friedman NR, Prager JD, Ruiz AG, Kezirian EJ. A pediatric grading scale for lingual tonsil hypertrophy. Otolaryngol Head Neck Surg. 2016;154:171---4. 6. 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. 7. Nakazawa K, Ikeda D, Ishikawa S, Makita K. A case of difficult vía aérea due to amigdala linguallar hypertrophy in a patient with Down’s syndrome. Anesth Analg. 2003;97: 704---5.
482 8. Golding-Wood DG, Whittet HB. The lingual tonsil. A neglected symptomatic structure? J Laryngol Otol. 1989;103:922---5. 9. Arrica M, Crawford MW. Complete upper airway obstruction after induction of anesthesia in a child with undiagnosed lingual tonsil hypertrophy. Paediatr Anaesth. 2006;16:584---7.
J. Sarmento Castro et al. 10. Tokumine J, Sugahara K, Ura M, Takara I, Oshiro M, Owa T. Lingual tonsil hypertrophy with difficult airway and uncontrollable bleeding. Anaesthesia. 2003;58:390---1.
Revista Española de Anestesiología y Reanimación www.elsevier.es/redar
CASE REPORT
Fiberoptic intubation in a child with previous unexpected difficult airway due to lingual tonsil hypertrophy夽 J. Sarmento Castro a,∗ , C.C. Costa a,b , H. Pereira a,c , R. Oliveira a , P. Santos a,c a
Anesthesiology Department, Centro Hospitalar São João, Porto, Portugal Anesthesiology Department, Centro Hospitalar Entre Douro e Vouga, Santa Maria da Feira, Portugal c Faculdade de Medicina da Universidade do Porto, Porto, Portugal b
Received 10 January 2019; accepted 4 March 2019 Available online 8 November 2019
KEYWORDS Airway management; Lingual tonsil hypertrophy; Fiberoptic intubation; Paediatric anaesthesia
PALABRAS CLAVE Manejo de la vía aérea; Hipertrofia de amígdala lingual;
Abstract Lingual tonsils are normal components of the oropharynx localized at the base of the tongue, which sometimes can become enlarged by inflammation. This may be a cause of unexpected difficult airway, considering most patients are asymptomatic and this supraglottic mass is not usually detected during a routine preoperative airway assessment. Commonly described in adults, there are limited reports in paediatric patients. We describe a case of a 12 years old boy diagnosed with a cerebellar brain tumour that was scheduled for a resection. The first surgery was postponed because of respiratory complications as a result of unexpected difficult airway due to lingual tonsil hypertrophy. His surgery was rescheduled and a plan for airway management was laid out: fibroscopic intubation with spontaneous ventilation. Considering this is a problem that cannot be identified by regular airway examination, we should be aware of the most effective ways to manage the situation as it arises. © 2019 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
Intubación con fibra óptica en un ni˜ no con dificultad de la vía no prevista previamente, debido a hipertrofia de amígdala lingual Resumen Las amígdalas linguales son componentes normales de la orofaringe, situadas en la base de la lengua, que a veces pueden agrandarse debido a inflamación. Esto puede ser causa de vía aérea difícil no prevista, considerando que muchos pacientes son asintomáticos
夽
Please cite this article as: Sarmento Castro J, Costa CC, Pereira H, Oliveira R, Santos P. Intubación con fibra óptica en un ni˜ no con dificultad de la vía no prevista previamente, debido a hipertrofia de amígdala lingual. Rev Esp Anestesiol Reanimac. 2019;66:478---482. ∗ Corresponding author. E-mail address: [email protected] (J. Sarmento Castro). 2341-1929/© 2019 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
Fiberoptic intubation in a child with lingual tonsil hypertrophy
Intubación con fibra óptica; Anestesia pediátrica
479
y que esta masa supra-glótica no es detectada habitualmente durante la valoración rutinaria preoperatoria de la vía aérea. Se describe de manera común en adultos, pero existen pocos informes sobre pacientes pediátricos. Describimos el caso de un ni˜ no de 12 a˜ nos, con diagnóstico de tumor cerebral cerebeloso, programado para resección quirúrgica. La primera cirugía se pospuso debido a complicaciones respiratorias como resultado de vía aérea difícil a causa de hipertrofia de la amígdala lingual. Se reprogramó la cirugía, estableciéndose un plan para el tratamiento de la vía aérea: intubación con fibra óptica con ventilación espontánea. Considerando que se trata de un problema que no puede identificarse mediante una exploración regular de la vía aérea, debemos tomar conciencia acerca de los modos más efectivos de manejar esta situación, cuando surja. © 2019 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Publicado por Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction Lingual tonsils are normal components of Waldeyer’s ring, consisting of small size lymphatic tissue, normally located at the base of the tongue.1,2 Enlargement of these structures, due to inflammation or hypertrophy, has been recognized as a possible cause of unexpected difficult airway and associated with negative outcomes.3,4 Lingual tonsil hypertrophy (LTH) may be asymptomatic and is usually not detected by a routine preoperative airway assessment. Commonly described in adults, there are limited reports regarding airway management difficulties caused by LTH in children. The degree of LTH can be assessed by the LTH grading scale,5 which ranges from 1 (minimal) to 4 (severe). We report a case of a child in which fiberoptic intubation was successfully achieved after previous unexpected difficult intubation due to a grade 4 LTH.
Case report A 12 year-old boy was scheduled for cerebellar pilocytic astrocytoma resection following a surgical intervention 4 years prior. Medical history included asthma and an adenotonsillectomy at the age of 2. No difficulty in ventilation or orotracheal intubation was observed in his previous anaesthesias. Airway assessment revealed mild retrognathia, normal mouth opening with welldefined visualization of oropharyngeal structures, tongue of normal size, Mallampati I, no limitations in neck mobility, and normal thyromental and sternomental distances. After induction of general anaesthesia (GA) with propofol (60 mg), fentanyl (0.15 mg) and rocuronium (40 mg), laryngoscopy was performed with a #3 Macintosh blade, showing a significant friable mass of lymphoid-like tissue arising from the base of the tongue and occupying the vallecula, with right predominance, corresponding to a grade 3 Cormack-Lehane view. Two attempts at blind intubation were unsuccessful and, after two further attempts by an
experienced paediatric anaesthesiologist using a #3 Macintosh blade and a frova intubating introducer, orotracheal intubation was finally achieved with a 6 mm reinforced cuffed endotracheal tube. The patient remained stable, but traumatic bleeding was detected during intubation attempts. He was immediately examined in the operating room by an otolaryngologist, who performed haemostatic control and took a specimen from the lesion. However, due to ventilation difficulties, surgery was postponed. The patient was extubated 4 days after surgery due to significant laryngeal oedema. Intubation was uneventful. Biopsy was interpreted as lingual tonsil hypertrophy, which was visible after reassessing previous cranial magnetic resonance imaging (MRI) (Fig. 1). This imaging study was not performed under anaesthesia. After reviewing the medical history, the patient’s parents indicated that he snored at night, but had no obstructive sleep apnoea. Surgery was rescheduled for 2 two months later. After explaining the procedure, the parents consented to fiberoptic intubation. In case of intubation failure, an otolaryngology team was available to perform a surgical airway. Prior to induction, adrenaline (1 mg) and dexamethasone (8 mg) spray was administered. Anaesthesia was induced with sevoflurane (4---8%; MAC < 1.6) in 100% O2 , maintaining spontaneous ventilation. Oral fiberoptic intubation was attempted with a 3.6 mm Karl Storz® fiberoptic bronchoscope, and initial airway visualization showed diffuse polypoid tissue extended from the base of the tongue to the midline of the vallecula and lingual aspect of the epiglottis, obscuring clear vision of the epiglottis and concealing the glottic opening (Fig. 2A---C). The vocal cords surrounding the tissues presented with significant symmetrical diffuse oedema (Fig. 2D). The cords were sprayed with 6 mL of 2% lidocaine and tracheal intubation was successfully achieved with a 6.5 mm reinforced cuffed tube with no signs of traumatic bleeding. The patient remained stable, and O2 saturation remained above 93%. Surgery was performed in the prone position and lasted for 3 h with no complications.
480
J. Sarmento Castro et al.
Figure 1
Preoperative cranial sagittal T1 weighted images, showing laryngeal obstruction caused by LTH (white arrows).
Figure 2 Initial airway fiberoptic view showing extensive enlargement of lingual tonsils, covering the vallecula and epiglottis borders with no visualization of the cords (A and B). Fiberoptic bronchoscope advancement showing significant swelling of the epiglottis (C) and tissue surrounding vocal cords (D).
After surgery, the patient was admitted to the paediatric ICU and was successfully extubated 24 h later in the presence of the attending paediatrician and otolaryngologist. He was discharged 1 week later with no complications.
Discussion LTH is a relatively frequent condition with an estimated prevalence of 2---3.2%.1,6 The aetiology is unknown, but
gastric reflux, obesity, chronic infections and history of tonsillectomy, as seen in this case, have been suggested.7 Two thirds of patients with LTH have a history of palatine tonsillectomy or adenoidectomy,7 and may be due to a compensatory mechanism after surgery in patients with repeated pharyngeal inflammatory episodes.4 Lingual tonsils are anatomically limited by the circumvallate papilla anteriorly and the epiglottis posteriorly,
Fiberoptic intubation in a child with lingual tonsil hypertrophy surrounding the entrance of the upper airway. Depending on their size, hypertrophied lingual tonsils can occupy the entire vallecula, override the tip and lateral borders of the epiglottis and displace this structure posteroinferiorly,3,4,7 causing difficult mask ventilation and tracheal intubation.4 Neuromuscular block may worsen laryngoscopy view by abolishing muscle support for the upper airway, and allowing posterior movement of the tongue and epiglottis. These difficulties can progress to a ‘‘cannot ventilate, cannot intubate’’ situation, which may result in the patient’s death.3 Nevertheless, it is difficult to anticipate complications arising from LTH, because most patients are asymptomatic and supraglottic masses are not detectable on a routine preoperative airway assessment. Our patient had a normal airway evaluation and difficult intubation was not anticipated. In a study of 33 patients with previous unexpected difficult intubation, Ovossapian et al.4 observed that LTH was the only common feature. However, airway examination was normal in all cases. Another important factor, as shown in our case, is that a history of previous successful intubations does not exclude subsequent difficulties in airway management.3 Consequently, LTH may only be detected preoperatively by fiberoptic laryngoscopy (FL) and indirect mirror laryngoscopy (IL).6 MRI, lateral neck X-ray, and computed tomographic scan are also important tools for the anaesthesiologist to identify supra-glottic masses.1 In our case, the first unexpected difficult intubation could have been anticipated if preoperative cranial MRI had been carefully evaluated. Therefore, the preoperative anaesthesia evaluation should include an analysis of previous imaging studies, in order to detect potential airway management problems. Nevertheless, despite risk factors for LTH, CT and MRI should not be routinely performed in all children because of radiation exposure, cost, limited availability, and the possible need for GA, respectively. FL and IL can be a safe and effective option in collaborative paediatric patients. Additionally, when the otolaryngologist detects LTH and recommends a procedure under GA, this information should be transmitted to the anaesthesiology team. Lingual tonsils are surrounded by a poorly organized capsule which makes them more vulnerable to trauma during continuous intubation attempts. Moreover, lingual tonsils and the supraglottic larynx share similar lymphatic drainage, allowing contiguous spread of oedema to the epiglottis.7 This may explain the generalized oedema we found during fiberoptic laryngoscopy. Considering the difficulties encountered in the first approach to this patient, we decided to perform oral fiberoptic intubation (FOI) in order to avoid airway swelling and bleeding. FOI is widely accepted as a valuable technique in the management of difficult airway, and is the gold standard for patients with known LTH.4 Difficult airway management in children with LTH is limited to a few cases reports. In one case, tracheal intubation was achieved by circumventing the supraglottic polypoid tissue using a straight blade.8 However, Go˜ ni-Zaballa et al.2 described failed intubation
481 despite the use of multiple devices. Tracheal intubation was only achieved after FOI guided by 3D CT scan imaging. In contrast to our case, this patient had significant predictors of difficult airway related to Klippel-Feil syndrome. Additional cases of LTH also required the use of FOI to successfully secure the airway.9,10 LTH continues to be an important cause of unanticipated difficult airway, because most patients are asymptomatic, and physical examination or previous medical history are not reliable predictors of complications. An understanding of the characteristics of LTH and early detection of this condition can prompt the anaesthesiologist to minimize airway manipulation in order to avoid negative outcomes. Although there is no perfect technique to secure the airway in these patients, FOI is recognized as the least traumatic and most likely to be effective. For these reasons, it should be the first option for anaesthesiologist experienced in the use of fiberoptic laryngoscopy. Finally, if all non-invasive techniques fail, anaesthesiologists should be familiar with invasive airway management.
Declaration of Competing Interest The authors declare that they have no conflict of interests
References 1. Sanchez-Morillo J, Gomez-Diago L, Rodriguez-Gimillo P, Herrera-Collado R, Puchol-Castillo J, Mompo-Romero L. Airway evaluation by indirect laryngoscopy in patients with lingual tonsillar hypertrophy [Article in English, Spanish]. Acta Otorrinolaringol Esp. 2013;64:345---51. 2. Go˜ ni-Zaballa M, Perez-Ferrer A, Charco-Mora P. Difficult airway in a pediatric patient with Klippel-Feil syndrome and an unexpected lingual tonsil. Minerva Anestesiol. 2012; 78:254---7. 3. Jones DH, Cohle SD. Unanticipated difficult airway secondary to lingual tonsillar hyperplasia. Anesth Analg. 1993;77: 1285---8. 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. Friedman NR, Prager JD, Ruiz AG, Kezirian EJ. A pediatric grading scale for lingual tonsil hypertrophy. Otolaryngol Head Neck Surg. 2016;154:171---4. 6. 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. 7. Nakazawa K, Ikeda D, Ishikawa S, Makita K. A case of difficult vía aérea due to amigdala linguallar hypertrophy in a patient with Down’s syndrome. Anesth Analg. 2003;97: 704---5.
482 8. Golding-Wood DG, Whittet HB. The lingual tonsil. A neglected symptomatic structure? J Laryngol Otol. 1989;103:922---5. 9. Arrica M, Crawford MW. Complete upper airway obstruction after induction of anesthesia in a child with undiagnosed lingual tonsil hypertrophy. Paediatr Anaesth. 2006;16:584---7.
J. Sarmento Castro et al. 10. Tokumine J, Sugahara K, Ura M, Takara I, Oshiro M, Owa T. Lingual tonsil hypertrophy with difficult airway and uncontrollable bleeding. Anaesthesia. 2003;58:390---1.