Adrian Williamson, Michael Kubala MD, Adam Johnson MD PhD, Megan Gaffey MD, and Gresham Richter MD
The lingual tonsils are a collection of lymphoid tissue found on the base of the tongue. The lingual tonsils along with the adenoid, tubal tonsils, palatine tonsils make up Waldeyer’s tonsillar ring. Hypertrophy of the lingual tonsils contributes to obstructive sleep apnea and lingual tonsillectomy can alleviate this intermittent airway obstruction.1,2 Lingual tonsil hypertrophy can manifest more rarely with chronic infection or dysphagia. A lingual tonsil grading system has been purposed by Friedman et al 2015, which rates lingual tonsils between grade 0 and grade 4. Friedman et al define grade 0 as absent lingual tonsils and grade 4 lingual tonsils as lymphoid tissue covering the entire base of tongue and rising above the tip of the epiglottis in thickness.3
Lingual tonsillectomy has been approached by a variety of different surgical techniques including electrocautery, CO2 laser, cold ablation (coblation) and microdebridement.4-9 Transoral robotic surgery (TORS) has also been used to improve exposure of the tongue base to perform lingual tonsillectomy.10-13 At this time, there is not enough evidence to support that one of these techniques is superior.
Here, we describe the microdebrider assisted lingual tonsillectomy in an 8 year-old female with Down Syndrome. This patient was following in Arkansas Children’s Sleep Disorders Center and found to have persistent moderate obstructive sleep apnea despite previous adenoidectomy and palatine tonsillectomy. Unfortunately, she did not tolerate her continuous positive airway pressure (CPAP) device. The patient underwent polysomnography 2 months preoperatively which revealed an oxygen saturation nadir of 90%, an apnea-hypopnea index of 7.7, and an arousal index of 16.9. There was no evidence of central sleep apnea. The patient was referred to otolaryngology to evaluate for possible surgical management.
Given the severity of the patient’s symptoms and clinical appearance, a drug induced sleep state endoscopy with possible surgical intervention was planned. The drug induced sleep state endoscopy revealed grade IV lingual tonsil hypertrophy causing obstruction of the airway with collapse of the epiglottis to the posterior pharyngeal wall. A jaw thrust was found to relieve this displacement and airway obstruction. The turbinates and pharyngeal tonsils were not causing significant obstruction of the airway. At this time the decision was made to proceed with microdebrider assisted lingual tonsillectomy.
First, microlaryngoscopy and bronchoscopy were performed followed by orotracheal intubation using a Phillips 1 blade and a 0 degree Hopkins rod. Surgical exposure was achieved using suspension laryngoscopy with the Lindholm laryngoscope and the 0 degree Hopkins rod. 1% lidocaine with epinephrine is injected into the base of tongue for hemostatic control using a laryngeal needle under the guidance of the 0 degree Hopkins rod. 1. The 4 mm Tricut Sinus Microdebrider blade was set to 5000 RPM and inserted between the laryngoscope and the lips to resect the lingual tonsils. Oxymetazoline-soaked pledgets were used periodically during resection to maintain hemostasis and proper visualization. A subtotal lingual tonsillectomy was completed with preservation of the fascia overlying the musculature at the base of tongue.
She was extubated following surgery and there were no postoperative complications. Four months after postoperatively the patient followed up at Arkansas Children’s Sleep Disorders Center and was found to have notable clinical improvement especially with her daytime symptoms. A postoperative polysomnography was not performed given the patient’s clinical improvement.
1. A drug induced sleep state endoscopy is performed to identify obstructive sleep apnea and the level of airway obstruction using a flexible bronchoscope through the nasal cavity.
2. Microlaryngoscopy and bronchoscopy followed by orotracheal intubation are then performed using a Phillips 1 blade and a 0 degree Hopkins rod.
3. Suspension laryngoscopy is obtained with a Lindholm laryngoscope.
4. 1% lidocaine with epinephrine is injected into the base of tongue for hemostatic control using a laryngeal needle under the guidance of the 0 degree Hopkins rod.
5. The 4 mm Tricut Sinus Microdebrider blade was set to 5000 RPM and inserted between the laryngoscope and the lips to resect the lingual tonsils.
6. Oxymetazoline soaked pledgets are used periodically for continued hemostasis.
The general indications for lingual tonsillectomy are lingual tonsil hypertrophy and lingual tonsil cancer. Lingual tonsillectomy for cancer cannot be performed by microdebridement if a surgical specimen is desired. Thus microdebrider assisted lingual tonsillectomy is performed for lingual tonsil hypertrophy cause obstructive sleep apnea and more rarely chronic infection or dysphagia.
1. Obstructive sleep apnea in a patient with palatine tonsil hypertrophy
2. Bleeding disorders
1. A flexible bronchoscope is used for the drug induced sleep state endoscopy.
2. A Phillips 1 blade and 0 degree Hopkins rod are used for microlaryngoscopy, bronchoscopy and intubation.
3. The Lindholm laryngoscope and 0 degree Hopkins rod are used for surgical exposure and visualization.
4. 1% lidocaine with epinephrine and oxymetazoline-soaked pledgets are used for hemostasis.
5. The 4 mm Tricut Sinus Microdebrider blade set to 5000 RPM is used for lingual tonsil resection.
1. Drug induced sleep state endoscopy
2. Polysomnography
1. Base of tongue
2. Lingual tonsils
3. Uvula
4. Epiglottis
5. Right and left vocal folds during microlaryngoscopy
6. Valleculae
7. Glossoepiglottic ligament
We feel that microdebrider assisted lingual tonsillectomy is comparable in safety and efficacy to other methods of resection. One of the primary concerns that surgeons may have with using the microdbrider is that it could cause more bleeding than other devices used for resection. However, we found bleeding to be minimal and well controlled with 1% lidocaine with epinephrine and oxymetazoline-soaked pledgets. The injection of 1% lidocaine with epinephrine was always performed with initial aspiration to avoid direct injection into a vessel. Another possible disadvantage of this method is injury to the lingual artery or the hypoglossal nerve. However, these adverse events has been avoided because all lingual tonsillectomies performed at Arkansas Children’s Hospital may be considered subtotal lingual tonsillectomies leaving the fascia overlying the musculature at the base of tongue intact.
Some advantages of microdebrider assisted lingual tonsillectomy performed in the described manner could be a shorter procedure time and improved surgeon comfort to perform lingual tonsillectomy. Lingual tonsillectomy procedure time is improved with this method because of the good exposure achieved with the Lindholm laryngoscope and 0 degree Hopkins rod.
Other methods of lingual tonsillectomy have employed coblation, cautery and CO2 laser. While these methods are able to easily achieve adequate hemostasis there is still potential to injure the lingual artery or hypoglossal nerve if the overlying musculature at the base of tongue is disturbed. Additionally, lingual tonsillectomy using the microdebrider could avoid the possible complication of oropharyngeal stenosis reported in some patients following some methods of lingual tonsillectomy (14). The emergence of robotic assisted lingual tonsillectomy has become popular in an attempt to improve surgical exposure. Here, we have demonstrated that appropriate surgical exposure is possible with the use of the Lindholm laryngoscope and 0 degree Hopkins rod.
The contributors to this video have no conflicts of interest or financial conflicts to disclose.
The contributors would like to thank the Department of Otolaryngology at Arkansas Children’s Hospital and the University of Arkansas for Medical Sciences for making this study possible. We would also like to thank CSurgeries for the educational opportunity that it provides.
Cited References:
1. Son EL, Underbrink MP, Qiu S, Resto VA. The surgical plane for lingual tonsillectomy: An anatomic study. J Otolaryngol Head Neck Surg. 2016;45:22-016-0137-3. doi: 10.1186/s40463-016-0137-3 [doi].
2. Lin AC, Koltai PJ. Persistent pediatric obstructive sleep apnea and lingual tonsillectomy. Otolaryngol Head Neck Surg. 2009;141(1):81-85. doi: 10.1016/j.otohns.2009.03.011 [doi].
3. Friedman M, Yalamanchali S, Gorelick G, Joseph NJ, Hwang MS. A standardized lingual tonsil grading system: Interexaminer agreement. Otolaryngol Head Neck Surg. 2015;152(4):667-672. doi: 10.1177/0194599815568970 [doi].
4. Abdel-Aziz M, Ibrahim N, Ahmed A, El-Hamamsy M, Abdel-Khalik MI, El-Hoshy H. Lingual tonsils hypertrophy; a cause of obstructive sleep apnea in children after adenotonsillectomy: Operative problems and management. Int J Pediatr Otorhinolaryngol. 2011;75(9):1127-1131. doi: 10.1016/j.ijporl.2011.06.003 [doi].
5. Barakate M, Havas T. Lingual tonsillectomy: A review of 5 years experience and evolution of surgical technique. Otolaryngol Head Neck Surg. 2008;139(2):222-227. doi: 10.1016/j.otohns.2008.01.009 [doi].
6. DeMarcantonio MA, Senser E, Meinzen-Derr J, Roetting N, Shott S, Ishman SL. The safety and efficacy of pediatric lingual tonsillectomy. Int J Pediatr Otorhinolaryngol. 2016;91:6-10. doi: S0165-5876(16)30337-8 [pii].
7. Krespi YP, Har-El G, Levine TM, Ossoff RH, Wurster CF, Paulsen JW. Laser lingual tonsillectomy. Laryngoscope. 1989;99(2):131-135. doi: 10.1288/00005537-198902000-00003 [doi].
8. Leitzbach SU, Bodlaj R, Maurer JT, Hormann K, Stuck BA. Safety of cold ablation (coblation) in the treatment of tonsillar hypertrophy of the tongue base. Eur Arch Otorhinolaryngol. 2014;271(6):1635-1639. doi: 10.1007/s00405-013-2845-x [doi].
9. Robinson S, Ettema SL, Brusky L, Woodson BT. Lingual tonsillectomy using bipolar radiofrequency plasma excision. Otolaryngol Head Neck Surg. 2006;134(2):328-330. doi: S0194-5998(05)01980-7 [pii].
10. Hoff PT, D'Agostino MA, Thaler ER. Transoral robotic surgery in benign diseases including obstructive sleep apnea: Safety and feasibility. Laryngoscope. 2015;125(5):1249-1253. doi: 10.1002/lary.25026 [doi].
11. Hurtuk A, Teknos T, Ozer E. Robotic-assisted lingual tonsillectomy. Laryngoscope. 2011;121(7):1480-1482. doi: 10.1002/lary.21767 [doi].
12. Leonardis RL, Duvvuri U, Mehta D. Transoral robotic-assisted lingual tonsillectomy in the pediatric population. JAMA Otolaryngol Head Neck Surg. 2013;139(10):1032-1036. doi: 10.1001/jamaoto.2013.4924 [doi].
13. Muderris T, Sevil E, Bercin S, Gul F, Kiris M. Transoral robotic lingual tonsillectomy in adults: Preliminary results. Acta Otolaryngol. 2015;135(1):64-69. doi: 10.3109/00016489.2014.952336 [doi].
14. Muderris T, Sevil E, Bercin S, Gul F, Kiris M. Oropharyngeal stenosis after transoral robotic lingual tonsillectomy. J Craniofac Surg. 2015;26(3):853-855. doi: 10.1097/SCS.0000000000001584 [doi].
Related CSurgeries Videos:
1. Modi, V. Lingual tonsillectomy with Epiglottopexy. CSurgeries. February 11, 2017. https://doi.org/10.17797/udyidw6jqh.
2. Mehta, D. Robotic Assisted Pediatric Lingual Tonsillectomy. CSurgeries. May 27, 2014. http://dx.doi.org/10.17797/q82n9gkkvs.
This video shows a transotic approach for a cochlear schwannoma in a 59-year-old female who presented with sudden sensorineural hearing loss in her left three years prior. She was found to have subsequent growth of her tumor on imaging and elected to undergo surgery. The transotic approach is a valuable approach within the armamentarium of a skull base team and differs from the transcochlear approach in the handling of the facial nerve. Techniques for ear canal overclosure, eustachian tube packing and mastoid obliteration are also highlighted.
Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.
Patient was taken up for procedure under general anaesthesia. She also started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively. The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.
The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.
Patient was called for follow up on post op day 14th and good voice outcomes were achieved.
So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
Review Microdebrider Assisted Lingual Tonsillectomy.