Hypertrophied Lingual Tonsils May Obstructed The Airway in Snoring Patient

Lingual Tonsillar Hypertrophy 

Hypertrophied Lingual Tonsils Obstructed The Airway in Snoring Patient

Image description: Snoring, difficulty breathing when lying on your back, sleep apnea (sleep apnea), night sweats, tired of waking up and hypertrophic lingual tonsil in patients with complaints that day feeling tired showing hypertrophy and closed airway photos (Images were obtained during flexible nasopharyngoscopy).

Etiology of lingual tonsillar hypertrophy

The etiology of hypertrophy of the lingual tonsillar tissue in an adult patient is uncertain and probably multifactorial and is thought to contribute to the pathophysiology of obstructive sleep apnea. Previous studies of lingual tonsil hypertrophy (LTH) in an adult patient have shown that lingual tonsils may undergo compensatory hyperplasia in children after tonsillectomy, although it is not known whether this has occurred.

Causes of hypertrophied lingual tonsils

The most common cause of lingual tonsillar enlargement is compensatory enlargement following tonsillectomy. Other potential causes include lymphoma, chronic infection, and HIV. Irritations such as smoking and gastroesophageal reflux disease (GORD) can also cause lingual tonsillar hypertrophy. As in this patient, immunosuppressant drugs are known to cause enlarged lingual tonsils.

Symptoms of of lingual tonsillar hypertrophy

In adults, lingual tonsillar hypertrophy is often asymptomatic. However, it may show vague symptoms such as sore throat, dysphagia, voice changes, foreign body sensation, coughing and suffocation, and obstructive sleep apnea. It is clinically important because of the potential for difficulty in intubation in anesthesia, especially since it cannot always be detected during routine oropharyngeal examination. It also has the potential to cause fatal airway obstruction.

Hypertrophied lingual tonsils can cause the sleep apnea and snoring!

Lingual tonsils consist of reactive lymphoid tissue at the the tongue base. Hypertrophy of lingual tonsils may occur clinically as globus, dysphagia and may cause difficulty in exposure to glottis during intubation. Lingual tonsillar hypertrophy (LTH) may also contribute to obstructive sleep apnea (OSA) at the oropharynx level. As shown in the photo, while breathing during sleep, the lingual tonsils on both sides close to each other and almost completely close the airway. In children, compensatory LTH was observed after routine tonsillectomy.

Treatment of of lingual tonsillar hypertrophy

Where possible, management should be directed to reasons such as the release of triggering agents, smoking, or medical management of pre-existing conditions, such as the initiation of a proton pump inhibitor in the GORD.

Surgical excision is recommended only if medical treatment fails and the patient remains symptomatic. The procedure is often difficult due to difficult access, poor visualization and difficult hemostasis. There is also a risk of airway edema and patients complain of excessive postoperative pain. Improved exposure can be achieved using suspension laryngoscopy or transoral endoscopy. In addition, excision can be performed using bipolar, scissors or thermal welding device. Other surgical techniques, including the use of CO2 laser and suction debrider, have been described in the literature, but bleeding is still an issue. Although coblation is still controversial as a method for palatine tonsillectomy, it appears to be a reasonable option with improved intraoperative hemostasis and therefore visualization. The most recent technique is transoral robotic surgery - although minimally invasive, both the high cost of the procedure and the availability of equipment limit this option in many centers.

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul

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