Failed tracheal intubation using a laryngoscope and intubating laryngeal mask

Abstract

Purpose: To report unexpected failed tracheal intubation using a laryngoscope and an intubating laryngeal mask, and difficult ventilation via a facemask, laryngeal mask and intubating laryngeal mask, in a patient with an unrecognized lingual tonsillar hypertrophy.Clinical features: A 63-yr-old woman, who had undergone clipping of an aneurysm seven weeks previously, was scheduled for ventriculo-peritoneal shunt. At the previous surgery, there had been no difficulty in ventilation or in tracheal intubation. Her trachea remained intubated nasally for 11 days after surgery. Preoperatively, her consciousness was impaired. There were no restrictions in head and neck movements or mouth opening. The thyromental distance was 7 cm. After induction of anesthesia, manual ventilation via a facemask with a Guedel airway was suboptimal and the chest expanded insufficiently. At laryngoscopy using a Macintosh or McCoy device, only the tip of the epiglottis, but not the glottis, could be seen, and tracheal intubation failed. There was a partial obstruction during manual ventilation through either the intubating laryngeal mask or conventional laryngeal mask; intubation through each device failed. Digital examination of the pharynx, after removal of the laryngeal mask, indicated a mass occupying the vallecula. Lingual tonsillar hypertrophy (1 × 1 × 2 cm) was found to be the cause of the failure. Awake fibrescope-aided tracheal intubation was accomplished.Conclusions: Unexpected lingual tonsillar hypertrophy can cause both ventilation and tracheal intubation difficult, and neither the laryngeal mask nor intubating laryngeal mask may be helpful in the circumstances. Éléments cliniques : Un shunt ventriculo-péritonéal a été planifié chez une femme de 63 ans qui avait subi une ligature d'anévrisme sept semaines auparavant,. Aucune difficulté d'intubation endotrachéale ou de ventilation n'avait eu lieu lors de cette opération. L'intubation nasale de la trachée a été maintenue pendant 11 jrs après l'intervention. Avant le shunt, on a noté des troubles de la conscience. Les mouvements de la tête et du cou ou l'ouverture de la bouche ne présentaient pas de limitations. La distance thyromentonnière était de 7 cm. Après l'induction de l'anesthésie, la ventilation manuelle au moyen d'un masque et d'une canule de Guedel était inadéquate et l'expansion thoracique insuffisante. Pendant la laryngoscopie à l'aide d'une lame Macintosh ou McCoy, seule la pointe de l'épiglotte, et non la glotte, a été visualisée et l'intubation a échoué. Il y a eu une obstruction partielle pendant la ventilation manuelle au travers du masque laryngé d'intubation ou du masque laryngé traditionnel; l'intubation a échoué aussi avec chacun des masques. Le masque laryngé une fois retiré, l'examen du pharynx au doigt a indiqué une masse occupant la fossette glosso-épiglottique. L'hypertrophie de l'amygdale linguale (1 × 1 × 2 cm) a été reconnue comme cause de l'échec. L'intubation fibroscopique vigile a été réalisée.Conclusions : L'hypertrophie méconnue de l'amygdale lingu...

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

“…Acute inflammation and hypertrophy can occur and has been reported to be one of the unusual causes of unexpected difficulties with both mask ventilation and tracheal intubation. [1][2][3] We present three cases of asymptomatic lingual tonsillar hypertrophy (LTH), each requiring different clinical interventions to secure the airway, including emergency cricothyroidotomy.…”

“…D Di is sc cu us ss si io on n The term lingual tonsil refers to a discrete mass of lymphoid tissue located at the base of the tongue. 2 Although there is considerable variation in the size and disposition of this tissue, when enlarged, one most commonly sees two lateral masses symmetrically placed on either side of the midline. These are divided by the glosso-epiglottic fold and may become so prominent that they fill the vallecula and displace the epiglottis posteriorly.…”

“…Jones and Cohle 1 were the first to report a death secondary to failed airway management in a patient with unrecognized LTH. More recently Asai et al 2 reported a case of suboptimal ventilation and failed tracheal intubation using various intubation strategies including the intubating laryngeal mask and fibreoptic endoscope.…”

“…It can be particularly useful in re-establishing ventilation and oxygenation when other measures have failed. However, the case report by Asai et al 2 highlights the fact that the LMA cannot always solve a truly glottic or subglottic problem; rather, the ventilatory mechanism must get below the lesion. 13 The authors further cautioned that the insertion of the LMA and subsequent intubation through the LMA are both blind techniques that can, potentially, damage pathological tissue near the laryngeal inlet.…”

“…13 The authors further cautioned that the insertion of the LMA and subsequent intubation through the LMA are both blind techniques that can, potentially, damage pathological tissue near the laryngeal inlet. 2,14 They suggest that in emergency situations preparation for a transtracheal airway be made during attempts at placement of the laryngeal mask, in the event that ventilation is inadequate. In our second case, it was speculated that insertion of the LMA between intubation attempts may have contributed to edema of the airway, despite a limited number of attempts at conventional laryngoscopy.…”