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Wong P, Sleigh JW. Airway management of lingual tonsillar hypertrophy: A narrative review. Anaesth Intensive Care 2024; 52:16-27. [PMID: 38006611 DOI: 10.1177/0310057x231196910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
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.
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Affiliation(s)
- Patrick Wong
- Department of Anaesthesia and Pain Medicine, Te Whatu Ora Health New Zealand Waikato, Hamilton, New Zealand
| | - Jamie W Sleigh
- Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
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Kim H, Song S. Difficult airway management in a patient with unexpected laryngeal deformities. Saudi J Anaesth 2022; 16:469-471. [DOI: 10.4103/sja.sja_75_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 11/04/2022] Open
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Ravindran B, Korandiarkunnel Paul F, Vyakarnam P. Acute upper airway obstruction due to tonsillitis necessitating emergency cricothyroidotomy. BMJ Case Rep 2021; 14:14/7/e242500. [PMID: 34321261 PMCID: PMC8319967 DOI: 10.1136/bcr-2021-242500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
A 17-year-old man was admitted to Accident & Emergency out of hours with unilateral tonsillar enlargement covering more than 75% of his oropharyngeal inlet. He appeared calm and stable on initial presentation, but in a short span of time rapidly deteriorated, leading to near complete airway obstruction necessitating an emergency awake cricothyroidotomy. Tracheostomy and tonsillectomy were done after this, he was ventilated postoperatively in intensive therapy unit and discharged home in a week. This is a rare clinical scenario in a patient presenting with palatine tonsillitis. A few subtle points in the history and examination alerted the team and prevented a risky inter hospital transfer for ear, nose and throat review. This is the first reported case in UK of palatine tonsillitis not due to infectious mononucleosis presenting with acute upper airway obstruction in a patient with no airway anomalies. It may also have been a varied presentation of COVID-19.
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Affiliation(s)
- Binu Ravindran
- Anaesthesia, Dartford and Gravesham NHS Trust, Dartford, UK
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Yamanaka H, Tsukamoto M, Hitosugi T, Yokoyama T. Mask Induction for an Intellectually Disabled Patient With Congenital Infiltrating Lipomatosis of the Face. Anesth Prog 2020; 67:98-102. [PMID: 32633775 DOI: 10.2344/anpr-67-01-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 09/23/2019] [Indexed: 11/11/2022] Open
Abstract
Airway management for patients with craniofacial disorders poses many challenges. Congenital infiltrating lipomatosis of the face (CILF) is an extremely rare disorder in which mature lipocytes invade adjacent tissues in the head and neck. The manifestations are typically unilateral, often with associated hypertrophy of both the hard and soft tissues of the face. This is a case report regarding the anesthetic management for a 5-year-old intellectually disabled female with CILF involving the right side of her face who underwent a successful intubated general anesthetic for dental treatment. Awake fiber-optic intubations are recommended and routinely used for patients with suspected or confirmed difficult airways. In this case, substantial distortion of the normal facial anatomy was observed clinically with noted hypertrophy of the right maxilla, mandible, and right side of the tongue. Further complicating matters was the patient's inability to fully cooperate because of her intellectual disability, precluding the option of an awake fiber-optic intubation. To secure the airway following mask induction of anesthesia, spontaneous ventilation was carefully maintained using sevoflurane, nitrous oxide, and oxygen combined with the application of a nasopharyngeal airway. Despite compression of the oral cavity and upper pharyngeal space by the hypertrophic tissues due to CILF, the space in and around the glottis was preserved. Intubation was completed easily with the use of a fiber-optic scope without any serious complications.
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Affiliation(s)
- Hitoshi Yamanaka
- Department of Dental Anesthesiology, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Masanori Tsukamoto
- Department of Dental Anesthesiology, Kyushu University Hospital, Fukuoka, Japan
| | - Takashi Hitosugi
- Department of Dental Anesthesiology, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Takeshi Yokoyama
- Department of Dental Anesthesiology, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
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Souki FG, Yemul-Golhar SR, Zeyed Y, Pretto EA. Lingual Tonsil Hypertrophy: rescuing the airway with videolaryngoscopy. J Clin Anesth 2016; 35:242-245. [PMID: 27871535 DOI: 10.1016/j.jclinane.2016.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/13/2016] [Indexed: 12/25/2022]
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.
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Affiliation(s)
- Fouad Ghazi Souki
- Department of Anesthesiology, Division of Transplantation, University of Miami/Jackson Health System, Miami, FL, USA.
| | | | - Yosaf Zeyed
- Department of Anesthesiology, University of Miami/Jackson Health System, Miami, FL, USA.
| | - Ernesto A Pretto
- Department of Anesthesiology, Division of Transplantation, University of Miami/Jackson Health System, Miami, FL, USA.
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8
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Costello R, Prabhu V, Whittet H. Lingual tonsil: clinically applicable macroscopic anatomical classification system. Clin Otolaryngol 2016; 42:144-147. [DOI: 10.1111/coa.12715] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2016] [Indexed: 11/27/2022]
Affiliation(s)
- R. Costello
- ENT Department; Singleton Hospital; Swansea UK
| | - V. Prabhu
- ENT Head and Neck Department; Singleton Hospital; Swansea UK
| | - H. Whittet
- ENT Head and Neck Department; Singleton Hospital; Swansea UK
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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]. ACTA ACUST UNITED AC 2014; 62:289-92. [PMID: 25487764 DOI: 10.1016/j.redar.2014.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 09/15/2014] [Accepted: 09/25/2014] [Indexed: 12/17/2022]
Abstract
Lingual tonsil hypertrophy can cause varying degrees of airway obstruction and is considered a risk factor for difficult mask ventilation and tracheal intubation. We report a case of unexpected difficult airway in a patient with unknown lingual tonsil hypertrophy that was solved with the use of the GlideScope video laryngoscope.
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Affiliation(s)
- P Cruz
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - L Alarcón
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - T Del Castillo
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - P Cabrerizo
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - S Díaz
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital General Universitario Gregorio Marañón, Madrid, España
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Batra UB, Usha G, Gogia AR. Anesthetic management of schwannoma of the base of the tongue. J Anaesthesiol Clin Pharmacol 2013; 27:241-3. [PMID: 21772689 PMCID: PMC3127308 DOI: 10.4103/0970-9185.81830] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Schwannoma arising from the base of the tongue are very rare and only a few cases have been reported so far. Definitive diagnosis is always made after a histological examination. Apart from an anticipated difficult airway with a risk of airway obstruction upon induction of general anesthesia, anesthetic concerns also include possibility of trauma to the growth and bleeding with attendant risks. We discuss the awake fiberoptic technique used for endotracheal intubation in such a case. This case report highlights the importance of detailed history taking and clinical examination, with emphasis on airway assessment and preoperative planning.
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Affiliation(s)
- Upma B Batra
- Department of Anaesthesia and Critical Care, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India
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Kumar N, Kumar R. Comment: Molar approach with backward, upward, right and posterior manoeuvre. Indian J Anaesth 2013; 57:431-2. [PMID: 24163476 PMCID: PMC3800354 DOI: 10.4103/0019-5049.118529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Patel AB, Davidian E, Reebye U. Complicated airway due to unexpected lingual tonsil hypertrophy. Anesth Prog 2012; 59:82-4. [PMID: 22822995 DOI: 10.2344/11-06.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Abdel-Aziz M, Ibrahim N, Ahmed A, El-Hamamsy M, Abdel-Khalik MI, El-Hoshy H. Lingual tonsils hypertrophy; a cause of obstructive sleep apnea in children after adenotonsillectomy: operative problems and management. Int J Pediatr Otorhinolaryngol 2011; 75:1127-31. [PMID: 21737150 DOI: 10.1016/j.ijporl.2011.06.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 06/06/2011] [Accepted: 06/09/2011] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Mosaad Abdel-Aziz
- Department of Otolaryngology, Faculty of Medicine, Cairo University, Egypt.
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Clavier T, Compère V, Hibon R, Hamou-Plotkine L, Dureuil B. [Lingual tonsil hypertrophy and unanticipated difficult airway management]. ACTA ACUST UNITED AC 2011; 30:375-6. [PMID: 21324635 DOI: 10.1016/j.annfar.2011.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Accepted: 01/12/2011] [Indexed: 10/18/2022]
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Orhan ME, Gözübüyük A, Sizlan A, Dere U. Unexpected difficult intubation due to lingual tonsillar hyperplasia in a thoracotomy patient: intubation with the double-lumen tube using stylet and fiberoptic bronchoscopy. J Clin Anesth 2009; 21:439-41. [PMID: 19833279 DOI: 10.1016/j.jclinane.2008.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2007] [Revised: 10/08/2008] [Accepted: 10/11/2008] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Mehmet E Orhan
- Department of Anesthesiology, Gülhane Military Medical Academy School of Medicine, Ankara, Turkey.
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Greenland KB, Cumpston PHV, Huang J. Magnetic Resonance Scanning of the Upper Airway following Difficult Intubation Reveals an Unexpected Lingual Tonsil. Anaesth Intensive Care 2009; 37:301-4. [DOI: 10.1177/0310057x0903700216] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- K. B. Greenland
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - P. H. V Cumpston
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - J. Huang
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Asbjørnsen H, Kuwelker M, Søfteland E. A case of unexpected difficult airway due to lingual tonsil hypertrophy. Acta Anaesthesiol Scand 2008; 52:310-2. [PMID: 17996002 DOI: 10.1111/j.1399-6576.2007.01485.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- H Asbjørnsen
- Department of Anaesthesia and Intensive Care Medicine, Haukeland University Hospital, Bergen, Norway.
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Augoustides JG, Groff BE, Mann DG, Johansson JS. Difficult airway management after carotid endarterectomy: utility and limitations of the Laryngeal Mask Airway. J Clin Anesth 2007; 19:218-21. [PMID: 17531732 DOI: 10.1016/j.jclinane.2006.06.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2005] [Revised: 06/14/2006] [Accepted: 06/15/2006] [Indexed: 11/19/2022]
Abstract
This case series details successful management of life-threatening airway obstruction after carotid endarterectomy. In the first case, ventilation was restored with a Laryngeal Mask Airway. In the second case, laryngeal mask airway rescue was unsuccessful, necessitating percutaneous transtracheal jet ventilation and subsequent endotracheal intubation with direct laryngoscopy.
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Affiliation(s)
- John G Augoustides
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, PA 19104-4283, USA.
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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. [PMID: 16677271 DOI: 10.1111/j.1460-9592.2005.01802.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Mauro Arrica
- Department of Anesthesia, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Szmuk P, Matuszczeak M, Carlson RF, David Warters R, Rabb MF, Ezri T. Use of CobraPLA for airway management in a neonate with Desbuquois syndrome. Case report and anesthetic implications. Paediatr Anaesth 2005; 15:602-5. [PMID: 15960646 DOI: 10.1111/j.1460-9592.2005.01489.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We present the anesthetic management of an infant with Desbuquois syndrome (a rare form of micromelic dwarfism) with a possible difficult airway. The anesthetic implications of this syndrome are presented. The airway was managed with a new supraglottic device - the CobraPLA. Although intubation through this device was not possible in this instance, CobraPLA provided a satisfactory supraglottic airway. It was easy to insert and provided satisfactory conditions for positive pressure ventilation. The CobraPLA provides another option for airway management.
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Affiliation(s)
- Peter Szmuk
- Department of Anesthesiology, University of Texas Medical School at Houston, TX 77030, USA.
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Abstract
Airway management is a critical part of anaesthesia practice. Management includes mask ventilation, laryngoscopy, endotracheal intubation and extubation of the patient. Difficulty can be encountered at any of these stages, potentially resulting in significant complications. Thorough preoperative assessment, as well as careful planning and preparation, can reduce the potential for complications. The American Association of Anesthesiologists (ASA) developed and recently revised guidelines for the management of the difficult airway. These guidelines focus on strategies for intubation as well as alternative airway techniques that can be used when a patient with a difficult airway is encountered.
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Affiliation(s)
- Lauren C Berkow
- Department of Anesthesia, Johns Hopkins Medical Institution, 600 Wolfe Street Meyer 8-134, Baltimore, MD 21287, USA.
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Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59:675-94. [PMID: 15200543 DOI: 10.1111/j.1365-2044.2004.03831.x] [Citation(s) in RCA: 786] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED Problems with tracheal intubation are infrequent but are the most common cause of anaesthetic death or brain damage. The clinical situation is not always managed well. The Difficult Airway Society (DAS) has developed guidelines for management of the unanticipated difficult tracheal intubation in the non-obstetric adult patient without upper airway obstruction. These guidelines have been developed by consensus and are based on evidence and experience. We have produced flow-charts for three scenarios: routine induction; rapid sequence induction; and failed intubation, increasing hypoxaemia and difficult ventilation in the paralysed, anaesthetised patient. The flow-charts are simple, clear and definitive. They can be fully implemented only when the necessary equipment and training are available. The guidelines received overwhelming support from the membership of the DAS. DISCLAIMER It is not intended that these guidelines should constitute a minimum standard of practice, nor are they to be regarded as a substitute for good clinical judgement.
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Affiliation(s)
- J J Henderson
- Anaesthetic Department, Gartnavel General Hospital, 1053 Great Western Road, Glasgow G12 0YN, UK.
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Nakazawa K, Ikeda D, Ishikawa S, Makita K. A case of difficult airway due to lingual tonsillar hypertrophy in a patient with Down's syndrome. Anesth Analg 2003; 97:704-705. [PMID: 12933389 DOI: 10.1213/01.ane.0000074347.64382.a4] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Koichi Nakazawa
- Department of Anaesthesiology & Critical Care Medicine, Tokyo Medical & Dental University School of Medicine, Tokyo, Japan
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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. [PMID: 12648128 DOI: 10.1046/j.1365-2044.2003.03095_10.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Cheng KS, Ng JM, Li HY, Hartigan PM. Vallecular cyst and laryngomalacia in infants: report of six cases and airway management. Anesth Analg 2002; 95:1248-50, table of contents. [PMID: 12401604 DOI: 10.1097/00000539-200211000-00026] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IMPLICATIONS This report describes difficulties encountered in the airway management of six infants with concurrent vallecular cyst and laryngomalacia. It is hoped that our experience will assist others in the management of such patients.
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Affiliation(s)
- Ka Shun Cheng
- Department of Anesthesiology, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan.
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