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 sur gery were subsequently found to have asymptomatic LTH. In all cases preoper ative airway examination was essentially unremarkable and no unusual diffic ulties were anticipated. In the first case, despite an inability to visuali ze the glottic opening, the patient was intubated successfully on the initi al 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. Ventil ation was maintained with a laryngeal mask airway (LMA) until the anestheti c was reversible. Upon awakening and removal of the LMA, the patient totall y obstructed and could not be ventilated, necessitating emergency cricothyr oidotomy. The third patient was an elderly gentleman in whom successful int ubation was eventually achieved, with considerable difficulty, by the otorh inolaryngologist (ENT surgeon) utilizing a straight blade. On a second occa sion, he was again intubated by the same ENT surgeon, this time utilizing t he anterior commissure blade. Adl three patients were subsequently discharg ed without further sequelae. Conclusion: Asymptomatic LTH can cause varying degrees of unexpected diffic ulty in securing the airway and, at present, no single method will necessar ily 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 o f a transtracheal airway.