Failed tracheal intubation using a laryngoscope and intubating laryngeal mask

Airway management of lingual tonsillar hypertrophy: A narrative review

Lingual tonsillar hypertrophy is rarely identified on routine airway assessment but may cause difficulties in airway management. We conducted a narrative review of case reports of lingual tonsillar hypertrophy to examine associated patient factors, success rates of airway management techniques and complications. We searched the literature for anaesthetic management of cases with lingual tonsillar hypertrophy. We found 89 patients in various case reports, from which we derived 92 cases to analyse. 64% of cases were assessed as having a normal airway. Difficult and impossible face mask ventilation occurred in 29.6% and 1.4% of cases, respectively. Difficult intubation and failed intubation occurred in 89.1% and 21.7% of cases, respectively. Multiple attempts (up to six) at intubation were performed, with no successful intubation after the third attempt with direct laryngoscopy. Some 16.5% of patients were woken up and 4.3% required emergency front of neck access. Complications included oesophageal intubation (10.9%), bleeding (9.8%) and severe hypoxia (3.2%). Our findings show that severe cases of lingual hypertrophy may cause an unanticipated difficult airway and serious complications, including hypoxic brain damage and death. A robust airway strategy is required which includes limiting the number of attempts at laryngoscopy, and early priming and performance of emergency front of neck access if required. In patients with known severe lingual tonsillar hypertrophy, awake intubation should be considered.

Zungengrundhyperplasie nach Tonsillektomie und Korrelation mit dem BMI

Hintergrund Die Hyperplasie der Zungengrundtonsille ist eine seltene und zugleich auch potenziell gefährliche Veränderung im Bereich der oberen Atemwege. Die Pathogenese der Zungengrundhyperplasie (ZGH) ist immer noch weitgehend unbekannt. Im Rahmen dieser Studie wurde der Zusammenhang zwischen Zustand nach Tonsillektomie und kompensatorischer Zungengrundhyperplasie untersucht.

Material und Methoden In der HNO-Klinik der Medizinischen Hochschule Hannover wurden 300 Patienten konsekutiv untersucht. Im Rahmen der indirekten Laryngoskopie wurden die Zungengrundtonsille, Einsehbarkeit des Larynx sowie seiner Subregionen nach einem Schema beurteilt. Die Daten wurden anschließend in Abhängigkeit vom Status der Gaumentonsillen ausgewertet. Ergänzend wurde der Body-Mass-Index (BMI) ermittelt und mit Ergebnissen der Laryngoskopie verglichen.

Ergebnisse Von den 300 untersuchten Patienten war bei 89 (29,6%) eine Tonsillektomie beidseits durchgeführt worden. In der Gesamtpopulation war eine stark vergrößerte Zungengrundtonsille nur in 14 Fällen (4,6%) nachweisbar. Von diesen 14 wurde bei 4 Patienten in der Vorgeschichte eine Tonsillektomie durchgeführt. Der BMI zeigte bei Patienten mit einer normal großen Zungengrundtonsille einen Wert von 24,4 und bei Patienten mit starker Zungengrundhyperplasie 27,3.

Schlussfolgerungen Die Inzidenz der ZGH fällt nach unseren Ergebnissen mit 4,7 % gering aus. Ein Zusammenhang zwischen einem Zustand nach Tonsillektomie und kompensatorischer Zungengrundhyperplasie konnte nicht nachgewiesen werden. Es zeigte sich jedoch ein statistisch signifikanter Zusammenhang zwischen BMI und ZGH.

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway

The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.

Lingual Tonsil Hypertrophy: rescuing the airway with videolaryngoscopy

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.

Assessment before airway management

It is wise to plan and prepare for the unexpected difficult airway. Although it is essential to take a history and examine every patient prior to airway management, preoperative anticipation of a difficult airway occurs in only 50% of patients subsequently found to have a difficult airway. Bedside screening tests lack accuracy. The modified Mallampati test and the measurement of thyromental distance are unreliable for prediction of difficult tracheal intubation. Knowledge of risk factors for various airway management techniques may help when devising an airway management plan.

The difficult airway with recommendations for management--part 2--the anticipated difficult airway

BACKGROUND

Appropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway.

METHODS

To review this and other subjects, the Canadian Airway Focus Group (CAFG) was re-formed. With representation from anesthesiology, emergency medicine, and critical care, CAFG members were assigned topics for review. As literature reviews were completed, results were presented and discussed during teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made, and levels of evidence were assigned.

PRINCIPAL FINDINGS

Previously published predictors of difficult direct laryngoscopy are widely known. More recent studies report predictors of difficult face mask ventilation, video laryngoscopy, use of a supraglottic device, and cricothyrotomy. All are important facets of a complete airway evaluation and must be considered when difficulty is anticipated with airway management. Many studies now document the increasing patient morbidity that occurs with multiple attempts at tracheal intubation. Therefore, when difficulty is anticipated, tracheal intubation after induction of general anesthesia should be considered only when success with the chosen device(s) can be predicted in a maximum of three attempts. Concomitant predicted difficulty using oxygenation by face mask or supraglottic device ventilation as a fallback makes an awake approach advisable. Contextual issues, such as patient cooperation, availability of additional skilled help, and the clinician's experience, must also be considered in deciding the appropriate strategy.

CONCLUSIONS

With an appropriate airway evaluation and consideration of relevant contextual issues, a rational decision can be made on whether an awake approach to tracheal intubation will maximize patient safety or if airway management can safely proceed after induction of general anesthesia. With predicted difficulty, close attention should be paid to details of implementing the chosen approach. This should include having a plan in case of the failure of tracheal intubation or patient oxygenation.

[Anesthesiological considerations for patients with trisomy 21 (Down syndrome)]

The most common chromosomal abnormality is trisomy 21 which is also known as Down syndrome and occurs in approximately 1 in 800 births. The majority of the resulting disabling conditions cannot be cured and affect people of all ages, ethnicity and economic levels. Life expectancy has increased with advances in medical care in the same way as in the rest of the population. One of the major tasks for health care professionals is to help these differently abled children and their families function in the most effective way possible as they learn to accept the limitations imposed by a persistent disability. Signs and symptoms of trisomy 21 are very variable based on the trias of mental retardation to a variable degree, hand anomalies and cardiac complications. Other abnormalities are atlantoaxial instability (AAI), tracheal stenosis, a predisposition to respiratory complications, chronic hypothyroidism, microgenia and macroglossia. These conditions are relevant to anesthetic procedures and patients with Down syndrome and their families have specific expectations and attitudes towards medical and anesthetic treatment.

Complicated airway due to unexpected lingual tonsil hypertrophy

We report an unexpected failed laryngeal mask airway in a patient with unrecognized lingual tonsil hypertrophy (LTH). A 19-year-old obese woman presented for extraction of multiple teeth via intravenous general anesthesia. Surgery was interrupted due to a laryngospasm midway through the procedure. The laryngospasm required the existing laryngeal mask airway to be removed so the patient could be suctioned. Although it is unclear the extent of obstruction caused by LTH, the surgery had to be postponed due to the discovery of enlarged lingual tonsils, which prevented endotracheal intubation. One reason for unexpected difficult airways is attributed to LTH. It is recognized that LTH is more common in patients with obstructive sleep apnea; however, LTH also has an increased prevalence in obese children with prior palatine tonsillectomies or adenoidectomies. Unexpected LTH can complicate general anesthesia by making placement of a laryngeal mask airway difficult. Thus, further research needs to be conducted to gain a deeper understanding on how to reduce the risks presented by LTH during sedation surgeries.

Lingual tonsils hypertrophy; a cause of obstructive sleep apnea in children after adenotonsillectomy: operative problems and management

OBJECTIVE

Although adenotonsillar hypertrophy has been reported to be the commonest cause of pediatric obstructive sleep apnea (OSA), enlargement of the lingual tonsils is increasingly being recognized as a cause, even after adenotonsillectomy. The aim of our study was to elucidate the lingual tonsils hypertrophy as a cause of pediatric OSA and also to evaluate the efficacy of lingual tonsillectomy in relieving symptoms of the disease considering the peri-operative problems and management.

METHODS

Sixteen children with lingual tonsils hypertrophy after adenotonsillectomy were included in the study. Computerized tomography (CT) and/or magnetic resonance imaging (MRI) were used for detection of the lesions. They underwent lingual tonsillectomy with special anesthetic care, flexible laryngoscopy and polysomnography were done pre- and post-operatively. Follow up of the patients was carried out for at least 1 year.

RESULTS

Three cases developed post-operative airway obstruction that is caused by tongue base edema. Complete improvement of snoring and apnea was achieved in 10 cases. Despite complete ablation of lingual tonsils, persistent snoring was detected in six cases, while apnea was detected in two cases. Down's syndrome, mucopolysaccharidoses, and obesity may be underlying factors for persistent symptoms.

CONCLUSIONS

Lingual tonsils hypertrophy could be the cause of obstructive sleep apnea in children after adenotonsillectomy, lingual tonsillectomy is an effective treatment for these cases, however peri-operative airway problems should be expected and can be managed safely. Persistent symptoms after lingual tonsillectomy may be due to the presence of co-morbidities such as cranio-facial deformities, obesity, and/or mucopolysaccharidoses.

Unexpected difficult intubation due to lingual tonsillar hyperplasia in a thoracotomy patient: intubation with the double-lumen tube using stylet and fiberoptic bronchoscopy

Lingual tonsillar hyperplasia is rare, and it may cause difficulty with tracheal intubation during induction of general anesthesia. A different orotracheal intubation technique was performed using a double-lumen endotracheal tube, flexible fiberoptic bronchoscope, and a stylet, in an unexpected difficult endobronchial intubation case due to massive lingual tonsillar hyperplasia.

Magnetic Resonance Scanning of the Upper Airway following Difficult Intubation Reveals an Unexpected Lingual Tonsil

We present a case of a 40-year-old woman requiring elective surgery who had an unexpected Grade 4 Cormack and Lehane laryngoscopy view. Both curved and straight laryngoscope blades in the sniffing and hyperextended head and neck positions were used. Endotracheal intubation was accomplished with some difficulty using a No. 3 Macintosh blade and Frova intubating catheter in the sniffing position. The cause of the difficult laryngoscopy was a lingual tonsil as shown in postoperative magnetic resonance scans.

We feel that a comprehensive postoperative evaluation should be conducted after every difficult laryngoscopy (Cormack and Lehane Grade 3b and 4). The use of magnetic resonance imaging may provide important objective information for both the anaesthetist and the patient, allowing a better understanding of causes and possible solutions for future airway management.

A case of unexpected difficult airway due to lingual tonsil hypertrophy

Clinical value of preoperative bedside screening tests for predicting difficult airway remains limited. Asymptomatic lingual tonsil hypertrophy is a known cause of unexpected difficult airway. We report a case as a reminder of this.

First clinical experience of tracheal intubation with the SensaScope, a novel steerable semirigid video stylet

BACKGROUND

Problems with tracheal intubation are a major cause of anaesthesia-related morbidity and mortality. Difficulty with tracheal intubation is primarily a consequence of failure to see the vocal cords with conventional direct laryngoscopy. We report our experience with use of the SensaScope for tracheal intubation in routine clinical practice.

METHODS

The SensaScope is a hybrid steerable semirigid S-shaped video stylet. Its handling and performance were assessed by anaesthetists with a minimum of 1 yr of experience. They performed four intubations each with the device in anaesthetized elective surgical patients. The view of the glottis with the Macintosh laryngoscope was compared with the view shown on the monitor by the SensaScope. The time taken to complete intubation, the final tracheal tube (TT) position and the degree of difficulty of the procedure were recorded.

RESULTS

Thirty-two patients were studied. All Macintosh Cormack and Lehane grade 3 patients were converted to grade 1 or 2 with the SensaScope. Mean intubation time was 25 (12) s and correct mid-tracheal TT cuff position was achieved in all cases. The degree of difficulty was 3.0 (1.8) on a numerical scale ranging from 0 to 10. All operators rapidly became familiar with the device and mastered its technique of use.

CONCLUSION

The SensaScope is a reliable and effective device for tracheal intubation under vision of the normal airway. It has great potential to facilitate management of difficult airway situations in anaesthetized and paralysed patients.

Complete upper airway obstruction after induction of anesthesia in a child with undiagnosed lingual tonsil hypertrophy

We present a case of a 9-year-old patient with previously undiagnosed lingual tonsil hypertrophy (LTH) that caused sudden and complete airway obstruction and inability to ventilate on induction of anesthesia. More frequently described in adults than in children, LTH can complicate mask ventilation, intubation or both, with the potential for catastrophic consequences.

A case of difficult airway due to lingual tonsillar hypertrophy in a patient with Down's syndrome

In this report, we describe airway management of symptomatic lingual tonsillar hypertrophy in a pediatric patient with Down's syndrome. Besides obstructive sleep apnea, the history included a small atrial septal defect with mild aortic regurgitation and Moyamoya disease. Anesthesia was induced with IV administration of 1 mg/kg of propofol, followed by inhalation of sevoflurane in 100% oxygen. Muscle relaxants were not used on induction. Rigid laryngoscopy could not visualize the epiglottis because of hypertrophied tonsillar tissue, and mask ventilation became difficult when spontaneous breathing stopped. We avoided using a laryngeal mask airway because of a slight bleeding tendency presumably caused by preoperative antiplatelet therapy. Fiberoptic bronchoscopy through the nasal cavity in combination with jet ventilation successfully identified the glottis and allowed nasotracheal intubation to be accomplished. After lingual tonsillectomy, the patient was extubated on the seventh postoperative day, after supraglottic edema had resolved. Fiberoptic nasotracheal intubation under inhaled anesthesia may therefore be preferable in pediatric or uncooperative patients with symptomatic lingual tonsillar hypertrophy.

Intubating laryngeal mask airway

The Intubating Laryngeal Mask Airway (ILMA) was introduced into clinical practice in 1997 following numerous clinical trials involving 1110 patients. The success rate of blind intubation via the device after two attempts is 88% in "routine" cases. Successful intubation in a variety of difficult airway scenarios, including awake intubation, has been described, with the overall success rate in the 377 patients reported being approximately 98%. The use of the ILMA by the novice operator has also been investigated with conflicting reports as to its suitability for emergency intubation in this setting. Blind versus visualized intubation techniques have also been investigated. These techniques may provide some benefits in improved safety and success rates, although the evidence is not definitive. The use of a visualizing technique is recommended, especially whilst experience with intubation via the ILMA is being gained. The risk of oesophageal intubation is reported as 5% and one death has been described secondary to the complications of oesophageal perforation during blind intubation. Morbidity described with the use of the ILMA includes sore throat, hoarse voice and epiglottic oedema. Haemodynamic changes associated with intubation via the ILMA are of minimal clinical consequence. The ILMA is a valuable adjunct to the airway management armamentarium, especially in cases of difficult airway management. Success with the device is more likely if the head of the patient is maintained in the neutral position, when the operator has practised at least 20 previous insertions and when the accompanying lubricated armoured tube is used.

Asymptomatic lingual tonsillar hypertrophy and difficult airway management: a report of three cases

PURPOSE

To report on the airway management of three cases of asymptomatic lingual tonsillar hypertrophy (LTH).

MATERIAL

On three separate occasions, patients presenting for elective surgery were subsequently found to have asymptomatic LTH. In all cases preoperative airway examination was essentially unremarkable and no unusual difficulties were anticipated. In the first case, despite an inability to visualize the glottic opening, the patient was intubated successfully on the initial attempt and had no further problems in the perioperative period. In the second case, neither direct laryngoscopy, utilizing the MacIntosh and McCoy blades, nor fibreoptic visualization enabled successful intubation. Ventilation was maintained with a laryngeal mask airway (LMA) until the anesthetic was reversible. Upon awakening and removal of the LMA, the patient totally obstructed and could not be ventilated, necessitating emergency cricothyroidotomy. The third patient was an elderly gentleman in whom successful intubation was eventually achieved, with considerable difficulty, by the otorhinolaryngologist (ENT surgeon) utilizing a straight blade. On a second occasion, he was again intubated by the same ENT surgeon, this time utilizing the anterior commissure blade. All three patients were subsequently discharged without further sequelae.

CONCLUSION

Asymptomatic LTH can cause varying degrees of unexpected difficulty in securing the airway and, at present, no single method will necessarily improve the chances of successful intubation. Therefore, strategies to manage unanticipated difficult intubation secondary to supraglottic airway pathology need to be performed and practiced, including the establishment of a transtracheal airway.