The unexpected difficult airway and lingual tonsil hyperplasia: a case series and a review of the literature

Anesthesiology. 2002 Jul;97(1):124-32. doi: 10.1097/00000542-200207000-00018.


Background: An unexpected difficult intubation occurs because physical examination of the airway is imperfect in predicting it. Lingual tonsil hyperplasia (LTH) is one risk factor for an unanticipated failed intubation that is not detectable during a routine oropharyngeal examination. The authors attempted to determine the incidence of LTH in unanticipated failed intubation in patients subjected to general anesthesia.

Methods: Thirty-three patients with unanticipated failed intubation via direct laryngoscopy were subjected to airway examinations and fiberoptic pharyngoscopy to determine the cause(s) of failure. Mouth opening, mandibular subluxation, head extension, thyromental distance, and Mallampati airway class were recorded. Fiberoptic pharyngoscopy was then performed to evaluate the base of the tongue and valleculae.

Results: Of these 33 patients, none had an airway examination that suggested a difficult intubation. The lungs of 12 patients were difficult to ventilate by mask. In 15 patients, airway measurements were within normal limits with Mallampati class of I or II. Ten patients had a Mallampati class III airway, 6 associated with obesity and 5 with mildly limited head extension. Among the 5 morbidly obese patients, most of the weight was distributed on the lower trunk and body. The 3 remaining patients had a thyromental distance of 6 cm or less but otherwise had a normal airway examination. The only finding common to all 33 patients was LTH observed on fiberoptic pharyngoscopy.

Conclusion: Lingual tonsil hyperplasia can interfere with rigid laryngoscopic intubation and face mask ventilation. Routine physical examination of the airway will not identify its presence. The prevalence of LTH in adults and the extent of its contribution to failed intubation is unknown.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Female
  • Humans
  • Hyperplasia
  • Intubation, Intratracheal*
  • Laryngeal Masks
  • Laryngoscopy
  • Male
  • Middle Aged
  • Palatine Tonsil / pathology*