1 INTRODUCTION

For the clinician and surgeon treating patients with obstructed sleep apnea and related maladies, the retrolingual airway is of much importance. This area, often difficult to examine and identify as an area of concern, has recently been the site of much academic and surgical attention. For with its difficult location comes increased complexity in surgical cure, plagued with both intraoperative and postoperative challenges. Although the palatal–pharyngeal area is often the site of primary obstruction in patients with sleep apnea, there are often areas of secondary blockage, andthe tongue base may be an area of interest with the added concern of hypertrophic lingual tonsils.

2 PATIENT SELECTION

Obstruction may not be the only presenting sign of hypertrophic lingual tonsils. Symptoms may be classified into two main categories, resulting from problems with either inflammation and infection or hypertrophy and hyperplasia. Inflammation may present with dysphagia and odynophagia with complaints originating at the tongue base or suprahyoid region. These symptoms may occasionally result in lingual tonsillar abscess and recurrent epiglottitis.1–3 Hypertrophic or hyperplastic tonsils may plague the patient with dysphagia and globus. These patients may have increased symptoms in the supine position, with those afflicted with obstructive sleep apnea having a worsening obstructive process in the deeper stages of sleep. Interestingly, lingual tonsil enlargement is a relatively common finding in children with persistent obstructive sleep apnea following adenotonsillectomy,4 further intensifying the finding of compensatory lingual tonsil hypertrophy after such a procedure.

The differentiation of lingual tonsil and tongue base pathology is often difficult. Furthermore, the very definition of lingual tonsil hypertrophy has not been standardized. However, if the lingual tonsils are greater than ‘10 mm in diameter and abutting both the posterior border of the tongue and the posterior pharyngeal wall,’ they may be considered clearly enlarged, due to a known relationship to patients with obstructive sleep apnea.5 Determination between lingual tonsil hypertrophy and an enlarged tongue base is critical, for these two entities often require different therapies with both needing attention. Careful history taking and physical examination when combined with ancillary studies may help the surgeon successfully treat the patient with retrolingual pathology.

There are multiple descriptions of how to surgically address the lingual tonsils, including scalpel, electrocautery, snares, laser and removal with the suction debrider.6–8 However, these procedures are often fraught with difficult exposure, painstaking dissection, poor visualization, difficult hemostasis, excessive postoperative pain and possible airway edema. A recent report from Robinson et al. describes the novel technique of utilizing bipolar radiofrequency plasma excision, or the coblator, for direct visual removal of the lingual tonsil pad using suspension laryngoscopy and an operating microscope.9