Difficult airway management in a case with lingual tonsil hypertrophy and temporo-mandibular joint partial ankylosis

provided the original work is properly cited. CC The lingual tonsil, a normal component of Waldeyer’s ring, consists of lymphoid tissue located at the base of tongue [1]. A supraepiglottic mass like lingual tonsillar hypertrophy (LTH) is recognized as a risk factor for unanticipated failed tracheal intubation, and lingual tonsil hypertrophy has been reported to be a cause of difficult airway [1]. Mask ventilation may be difficult or impossible in proportion to the degree of hypertrophy. We report a case of difficult airway resulting from LTH combined with moderate temporo-mandibular joint ankylosis. We obtained a written, informed consent from the patient about using the information of the patient. A 62-year-old male patient (Height 165 cm, weight 67 kg) was scheduled for radicular cyst excision in the anterior maxilla. In the physical examination, there was moderately limited neck mobility, 4 cm mouth opening with moderately retracted mandible, 6 cm thyromental distance, and Mallampati class III. Preoperative blood tests, electrocardiogram, and chest radiograph were normal. His past medical history was unremarkable except for well controlled hypertension. Following placement of routine monitoring and preoxygenation, anesthesia was induced with 60 mg lidocaine, 100 mcg fentanyl, 120 mg propofol, in combination with 50 mg rocuronium. Unexpectedly, mask ventilation was difficult, needing an oral airway and two person mask ventilation. When we gave positive pressure to the airway of the patient, we could see his cheek and submandibular area bulging like a balloon as if there was an obstruction in the supraglottic area. Laryngoscopy revealed a Grade 4 Cormack and Lehane view and BURP (backward upward right pressure) maneuver could not improve the view. An experienced anesthesiologist performed oral intubation with flexible fiberoptic bronchoscopy (FOB). However, the tongue base totally obstructed the pharyngeal cavity, and we could not advance the bronchoscope. We tried to clear the airway with chin lift with neck extension, but unexpectedly jaw protraction was almost impossible due to temporo-mandibular (TM) joint partial ankylosis. We tried direct laryngoscopy with a #3 Macintosh blade to retract the tongue base to make way for FOB. We could advance the fiberoptic bronchoscope under the laryngoscope blade and a normal shaped epiglottis and vocal cords were partially visible. A #7.5 cuffed plain endotracheal tube was inserted successfully. Following completion of the surgery, the muscle relaxation was recovered, and the patient was extubated without incident. After surgery, the patient was referred to otolaryngology, and a massive LTH was confirmed with direct laryngoscopy and computed tomography (Fig. 1). His subsequent course was uneventful, and he was discharged home 3 days later. The etiology of LTH is not known precisely. Mainly, hypertrophy may occur due to compensation for the removal of palatine tonsils, chronic infections, allergy, and reflux of gastric contents [1]. LTH can occupy the entire vallecula and override the tip and lateral borders of the epiglottis. LTH can displace the epiglottis posteriorly, causing dysphagia and respiratory obstruction. Most LTH is asymptomatic and is not visible during the regular physical examination [1]. Ovassapian et al. [1] analyzed 33 patients who had a history of failed endotracheal intubation and difficult airway. The only common finding was LTH. Sixty-four percent of the patients’ airway risk index scores were estimated at 0 to 1 which means 95% chance of easy intubation. There were 12 patients with dif-