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Department of Anaesthesia,, Dumfries and Galloway Royal Infirmary, Dumfries, United Kingdom
To the Editor:
"The tissue at the base of the tongue is a most fertile source of trouble" (1).
Nakazawa et al. report their management of a child requiring reduction of lingual tonsillar hypertrophy (LTH) (2). They rightly mention that bleeding from LTH is a real risk (3). They do not mention which type of laryngoscope blade was used. The use of a curved (Macintosh) blade can be a disadvantage in such patients, because the tip of the blade is designed to enter the vallecula. In patients with LTH, this may fail and cause bleeding into the airway.
An alternative approach is the paraglossal straight blade technique, which has been reviewed by Henderson (4). This involves passing a straight bladed laryngoscope into the right side of the mouth, advancing along the groove between tongue and palatine tonsil. The blade tip is passed posterior to the epiglottis, which is elevated directly, exposing the glottic aperture. This technique does not subject the patient’s tongue to the compressive forces of the Macintosh blade and can displace tongue base tissue into the laryngoscopic "line of sight." Also, this technique can spare the tongue base from the potential trauma of a curved blade.
We think this technique deserves wider recognition.
References
Department of Anesthesiology and Critical Care Medicine, Tokyo Medical and Dental University, Tokyo, Japan
In Response:
In our routine anesthetic practice, a curved Macintosh blade is used for tracheal intubation and thus was used in our case. We also agree that Macintosh technique should be avoided in lingual tonsillar hypertrophy, because it involves the base of tongue and compression of the tissues above the epiglottis is inevitable.
In our case, we did not expect a laryngeal view and just wanted to observe how large the tonsil was and how it looked like, i.e., whether there was a space for the fiberscope or supraglottic airway devices between the tonsils. The conclusion we obtained from the observation was that insertion of any supraglottic airway devices or laryngoscope blades such as a Bullard laryngoscope would be dangerous. We are not sure whether paraglossal or lateral approach (1) was efficacious in this case, because the straight blade might not bypass the tongue without compressing the tonsillar tissues.
The Macintosh technique usually provides a better intubating condition compared with the Miller blade, as shown in a recent study (2). However, one must remember that the Miller blade gives a better view in cases with large incisors, a long, floppy epiglottis, anterior larynx, and a small mandibular space (3). Also, as Dr. Jefferson pointed out, the Miller blade reduces soft tissue compression above the epiglottis. Hastings et al. (4) demonstrated that force and head extension were 30% less with the Miller blade compared with the Macintosh. Minimizing laryngoscopic force and torque may be favorable for difficult laryngoscopy with lesions at the base of the tongue.
Unfortunately, we are not familiar with the paraglossal approach using a straight blade. Since more skills are necessary in taking this approach (1), we feel that the technique should be adopted in routine practice so that we can use it with confidence in the face of difficult laryngoscopy.
References
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