Base of Tongue Non-Hodgkin’s Lymphoma: Difficult Intubation

Hazem Kafrouni,Joui Makhoul

doi:10.31487/j.scr.2021.08.12

Abstract

Primary Non-Hodgkin’s Lymphoma (NHL) of the tongue is a very rare tumor most commonly affecting elderly patients causing upper airway obstruction and anticipated difficult intubations with space occupying lesions that prevent tongue displacement and hence, scarce space for laryngoscopy. A 78-year-old man presented with progressive stridor and dyspnea. Oral examinations revealed tongue asymmetry and friable ulcerative lesions. During induction of anaesthesia in a scheduled partial glossectomy, difficult nasotracheal intubation was encountered despite using the Glidescope. Laryngeal landmarks could not be identified but successful nasotracheal intubation by hand-assisted and magill forceps manipulation of the endotracheal tube direction under video laryngoscopy. Failed intubation should always be considered in the management of base of tongue tumors. Pre-operative assessment and planning to secure the airway in patients presenting with base of tongue tumors decreases morbidity and mortality, especially when an emergency plan is prepared. No single airway management technique can be used for every patient. Further research is required for guiding the choice of airway management in such patients.

Highlights

Oral presentations are present in 3-5% of cases of Non-Hodgkin’s Lymphoma (NHL), an uncommonly encountered and very rare tumor of the base of tongue [1]
It is safer to secure the airway while spontaneous breath is initiated than if general anaesthesia is induced before tracheal intubation
Despite being gold standard for management of difficult intubation, fiberoptic intubation might be impeded by the massive tumor and distorted anatomy of the oropharynx as in our current case and in some similar base of tongue tumors’ case reports discussed in the literature

Summary

Introduction

Oral presentations are present in 3-5% of cases of Non-Hodgkin’s Lymphoma (NHL), an uncommonly encountered and very rare tumor of the base of tongue [1]. Upper airway and laryngeal inlet views are beneficial in recognizing patients in whom an awake technique is more relevant [5] This case examines the significance of a thorough preoperative assessment and preparation, especially in patients with expected oropharyngeal obstruction, complete cooperation between the anaesthesiologist and surgeon preoperatively and intraoperatively to avoid life threatening complications and to reduce morbidity and mortality. Concerned about difficult/impossible direct laryngoscopy because of the space occupying lesion in the floor of the mouth (Figure 2), we planned video laryngoscopy to secure the airway along with rapid sequence induction and intubation and a trial of ventilation.

Findings

Discussion

Conclusion