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PEDIATRIC ANESTHESIA

A Case of Difficult Airway Due to Lingual Tonsillar Hypertrophy in a Patient with Down’s Syndrome

Department of Anaesthesiology & Critical Care Medicine, Tokyo Medical & Dental University School of Medicine, Tokyo, Japan

Address correspondence and reprint requests to K. Nakazawa, MD, Department of Anaesthesiology & Critical Care Medicine, Tokyo Medical & Dental University School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo 1138519, Japan. Address e-mail to nakazawa.mane{at}tmd.ac.jp

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.

IMPLICATIONS: We report a case of airway management of symptomatic lingual tonsillar hypertrophy (LTH) in a patient with Down’s syndrome. Fiberoptic nasotracheal intubation while maintaining spontaneous breathing under inhaled anesthesia may be preferable in pediatric or uncooperative patients with LTH.

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				M. Al Shamaa, P. Jefferson, D. R. Ball, K. Nakazawa, D. Ikeda, S. Ishikawa, and K. Makita Lingual Tonsillar Hypertrophy: Airway Management Using Straight Blade Direct Laryngoscopy * Response Anesth. Analg., March 1, 2004; 98(3): 874 - 875. [Full Text] [PDF]