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
1. Base of tongue
2. Lingual tonsils
5. Right and left vocal folds during microlaryngoscopy
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.
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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.