Lingual Tonsillar Hypertrophy Research Articles

Airway management of lingual tonsillar hypertrophy: A narrative review.

Lingual tonsillar hypertrophy is rarely identified on routine airway assessment but may cause difficulties in airway management. We conducted a narrative review of case reports of lingual tonsillar hypertrophy to examine associated patient factors, success rates of airway management techniques and complications. We searched the literature for anaesthetic management of cases with lingual tonsillar hypertrophy. We found 89 patients in various case reports, from which we derived 92 cases to analyse. 64% of cases were assessed as having a normal airway. Difficult and impossible face mask ventilation occurred in 29.6% and 1.4% of cases, respectively. Difficult intubation and failed intubation occurred in 89.1% and 21.7% of cases, respectively. Multiple attempts (up to six) at intubation were performed, with no successful intubation after the third attempt with direct laryngoscopy. Some 16.5% of patients were woken up and 4.3% required emergency front of neck access. Complications included oesophageal intubation (10.9%), bleeding (9.8%) and severe hypoxia (3.2%). Our findings show that severe cases of lingual hypertrophy may cause an unanticipated difficult airway and serious complications, including hypoxic brain damage and death. A robust airway strategy is required which includes limiting the number of attempts at laryngoscopy, and early priming and performance of emergency front of neck access if required. In patients with known severe lingual tonsillar hypertrophy, awake intubation should be considered.

Avascular midline oropharyngeal anatomy allows for expanded indications for transoral robotic surgery in pediatric patients.

Transoral robotic surgery (TORS) in children is in its infancy, and indications have been primarily limited to lingual tonsillar hypertrophy and superficial mucosal lesions. However, the relatively avascular channel of the midline posterior tongue, vallecula, and posterior hyoid space provides a safe plane of dissection for deep lesions of the tongue and access to structures in the anterior neck. As robotic surgeons gain experience, application of this technology will continue to grow. The method is retrospective case series. We present seven patients who had either a primary (n = 3) or recurrent (n = 4) lingual thyroglossal duct cyst (TGDC) and underwent TORS excision. Four of the seven patients also underwent transoral resection of the central portion of the hyoid bone, while three had central hyoid resection during prior surgery. Two minor complications occurred with no evidence of lesion recurrence after mean follow-up of 19.7 mo. The midline avascular channel of the tongue allows for relatively bloodless surgical access to pathologies of the midline base of tongue and anterior neck. Lingual thyroglossal duct cysts can safely be removed via aTORS approach with evidence of limited recurrence. Robotic technology can provide safe and effective surgical alternatives for children with a variety of pathologies, and we aim to promote the widespread adoption of TORS in pediatric head and neck surgery by sharing our knowledge and clinical experience. Further study and publication are needed to establish safety and efficacy.

149 - A difficult diagnosis to swallow - lingual tonsillar hypertrophy

149 - A difficult diagnosis to swallow - lingual tonsillar hypertrophy

Variations in Polysomnographic Indices of Obstructive Sleep Apnea following Lingual Tonsil Hypertrophy Excision: Is the Difference Significant?

Background and Objectives: Obstructive sleep apnea (OSA) is a sleep-related respiratory disorder that affects between 5% and 20% of the population. In obstructive sleep apnea, lingual tonsillar hypertrophy (LTH) has been suggested as a contributing factor to airway blockage. Objectives: The aim of this work is to demonstrate the polysomnographic indices and their values in OSA patients with LTH before and after the surgical intervention. Materials and Methods: The study was conducted on eighteen patients endoscopically diagnosed as having LTH, with the main complaints being snoring, sleep apnea, and/or sleep disturbance. Clinical examination, grading of LTH, body mass index (BMI), endoscopic assessment using Muller’s maneuver, and sleep endoscopy were recorded for all patients. The Epworth Sleepiness Scale (ESS) and overnight sleep polysomnography (PSG) were conducted before and after the surgical removal of LTH. All data were submitted for statistical analysis. Results: The mean ± SD of the AHI decreased from 33.89 ± 26.8 to 20.9 ± 19.14 postoperatively, and this decrease was of insignificant statistical value. The average SpO2 (%) mean ± SD was 91.14 ± 5.96, while the mean ± SD of the desaturation index was 34.64 ± 34.2. Following surgery, these indices changed to 96.5 ± 1.47 and 9.36 ± 7.58, respectively. The mean ± SD of the ESS was changed after the surgery, from 17.27 ± 6.48 to 7.16 ± 3.56. The mean ± SD of sleep efficacy was 71.2 ± 16.8 and the snoring index mean ± SD was 277.6 ± 192.37, and both improved postoperatively, to become 88.17 ± 9.1 and 62.167 ± 40.01, respectively. Conclusions: The AHI after lingual tonsillectomy showed no statistically significant change. The changes in the average SpO2 (%), desaturation index, sleep efficiency, snoring index, and Epworth Sleepiness Scale following the surgery were statistically significant.

Lingual tonsillar hypertrophy, an unknown enemy

We report an unexpected difficult airway in a patient with unrecognized lingual tonsillar hypertrophy. A 54-year-old hypertensive woman presented for resection of a mediastinal mass under general anesthesia (GA). After induction, mask ventilation was impossible. Laryngeal mask airway (LMA) was used, achieving suboptimal ventilation. Fiberoptic intubation through LMA was attempted but tube advancement was hindered by a protrudingmass. Finally, intubation was achieved using the Frova introducer. After completion of the surgery, the patient was transferred, intubated, to the postanesthesia care unit. Ear, nose, and throat assessment concluded that the mass was a hyper-trophied lingual tonsil. Unexpected lingual tonsillar hypertrophy can complicate GA, making mask ventilation, and even intubation impossible. It is considered a frequent cause of unexpected difficult airway. Diagnosis cannot be made by standard airway physical examination. Once recognized, fiberoptic intubation is mandatory in subsequent surgeries.

Lingual tonsils hypertrophy and possibility of its correction by physical factors

Introduction: The component of the lymphopharyngeal ring is the lingual tonsil (LT), located on the root of the tongue. With pathological changes in the lymphoid tissue of the pharynx, surgical removal of the tonsils, as a result of increased antigenic load, a compensatory increase in LT is observed – «lingual tonsillar hypertrophy». This is observed against the background of age-related involutive changes, when the remaining elements of the lymphopharyngeal ring begin to perform anti-antigenic and adaptive activity. The processes taking place in, the structure of the LT, which is familiar to the body, changes - the receptor apparatus creates pathological impulses from the organ. The severity of clinical manifestations correlates with the degree of increase in LT. The emphasis on these manifestations, psychosomatic conditions, create a complex of pathological sensations that violate the quality of patients’ life. The goal and objectives of the study are aimed at improving the quality of patients’ life with lingual tonsil hypertrophy (LTH), by developing effective methods of diagnosis and treatment, assessing the role of the immunoregulatory shift in the pathogenesis of LTH of the possibility of their correction by the action of a physical factor (cold destruction). Materials and methods: When examining 850 people who underwent complex research and instrumental diagnostics in connection with the pathology of ENT organs, 119 people (the main group) were diagnosed with different degrees of LTH, with control of 30 healthy people. Cryosurgical treatment was offered to 76 patients who used the method for treating of lingual tonsil hypertrophy by cryodestruction using a hook-shaped applicator with a heat-insulating nozzle on the back surface, an individual polyethylene cap, and a cryoapparatus. Results and discussions: With LTH, an increase in the volume and mass of tissues forming the morphological basis of the tonsil was detected: the main substance was an increase in the number and size of layers of coarse fibrous fibers, fields of fat cells, and the growth of mucous glands. The mucous membrane, thinning, undergoes dystrophic-degenerative changes. The rate of proliferation correlates with the severity of inflammation, the causes of which are multifactorial, individual. There is an increased sensitivity reaction to microbial and household allergens, an increase in the content of antibodies in the blood to LT tissues, a change in microbiocinosis of the pharyngeal mucosa, and vegetation of non-resident microflora. As a result of cryosurgical treatment in 56 (73.68%) cases, a decrease in the volume of LT tissue was observed. The deep layers, partially absorbed, were replaced by healthy tissues, the surface layers were rejected with the formation of an atrophic scar or regenerate, the structure of which was close to organotypic. The cause of pathological impulse was eliminated, clinical indicators were normalized, the quality of life of patients was improved. Conclusions: LTH should be considered as a continuation of the development of a productive process associated with immunoregulatory changes in chronic infectious and allergic conditions. Local cryogenicity on LTH was accompanied by normalization of the structure of its own substance, LT, and a decrease in inflammatory changes in surrounding tissues. The development of inflammatory changes in LT was a local manifestation of a general disturbance in the functioning of the immune defense system. Achieving a persistent positive effect in the treatment of LTH requires an integrated approach with mandatory systemic immune correction and hormonal correction.

Robot-assisted Tongue Base Resection ensures favorable therapeutic outcome to Obstructive Sleep Apnea patients with Lingual tonsil hypertrophy

Tongue base (TB) narrowing is recognized as a significant site of upper airway collapse during sleep in obstructive sleep apnea (OSA) patients and robot technology is expected to have promising clinical utility in OSA patients with TB narrowing. The purpose of our study is to demonstrate the better therapeutic conditions and favorable indications of robot-assisted TB resection (TBR) in OSA. We performed robot-assisted TBR combined with nasal and palatal surgery in 16 OSA patients with any of the following characteristics: severe TB narrowing (over grade II) and moderate or severe OSA. The preoperative median AHI was 48.8/hr and the median lowest SaO2 was 82.0%. The median AHI decreased to 18.7/hr and ten patients (62.5%) were included in the responder group following robot-assisted TBR combined with nasal and palatal surgery. The lowest SaO2 improved to 90.5% and the posterior airway space (PAS) was significantly increased following robot-assisted TBR. Cephalometric results showed that wider PAS were observed in responders compared to non-responders prior to robot-assisted TBR. Interestingly, there was greater improvement in the objective parameters including PAS in the OSA patients with lingual tonsilar hypertrophy than they were in those without and all patients with lingual tonsillar hypertrophy (n = 6) responded to robot-assisted TBR. Robot-assisted TBR exhibited minimal morbidity and postoperative complications in OSA patients. Robot-assisted TBR can be considered a promising and innovative surgical option to reduce TB volume and improve sleep parameters in OSA patients with TB narrowing. OSA patient with TB narrowing due to lingual tonsil hypertrophy shows greater therapeutic outcome and lingual tonsil hypertrophy appears to be most favorable surgical indications of robot-assisted TBR.

An unusual case of lingual tonsillar hypertrophy.

Key Clinical MessageLingual tonsillar hypertrophy is an unusual presentation of voice change. If managed incorrectly this group of patients has the potential to deteriorate significantly causing airway obstruction and potentially death.

Transoral robotic surgery for sleep apnea in children: Is it effective?

ObjectivesChildren with obstructive sleep apnea/hypopnea syndrome (OSAHS) as a result of base of tongue (BOT) or lingual tonsillar hypertrophy do not improve following adenotonsillectomy. In adults, transoral robotic surgery (TORS) offers a means of treating such patients, however the efficacy of this technique for children is not known. In this study, we examine the effectiveness of TORS BOT reduction and lingual tonsillectomy for treatment of pediatric OSAHS. MethodsThis was a retrospective study of nine patients (5 non-syndromic; 4 syndromic) who underwent isolated BOT reduction and lingual tonsillectomy for OSAHS between 2012 and 2014 at a tertiary care pediatric medical center. Differences between pre and post surgical polysomnograms (PSGs) were utilized to measure the procedural effectiveness. Patient age, sex, body mass index (BMI), developmental status, and comorbid conditions were also examined. ResultsThe average patient age was 10.5 years (range 5.2–18.5). There were 5 males and 4 females. The mean pre-operative obstructive AHI (O-AHI) was 27.1 compared to 10.9 post-operatively (mean difference=16.1, t=2.27, p≤0.05). Statistically significant reductions were also noted in hypopneic events (mean difference=61.3, t=2.64, p<0.05) and lowest oxygen saturation (mean difference=9.0, t=−3.29, p≤0.01). One patient developed a post-operative bleed that was controlled operatively. ConclusionsIn children with airway obstruction associated with BOT and lingual tonsillar hypertrophy, TORS is a useful and effective tool. Patients’ who underwent TORS demonstrated a significant decrease in obstructive events. All patients reviewed exhibited at least a 50% reduction in O-AHI.

OSAS Due to Massive Lingual Tonsillar Hypertrophy in 8-Year-Old Boy with Delta-Beta-Thalassemia – A Case Report

A few case reports describe an association of airway obstruction due to lingual tonsillar hypertrophy in patients with thalassemia. We present an eight-year- old boy with a history of delta-beta-thalassemia and recurring lingual tonsillar hypertrophy. We hypothesize that this could be the result of extramedullary hematopoiesis.

Transoral robotic lingual tonsillectomy in adults: preliminary results

Conclusion: Hypertrophy of lingual tonsils can be safely and effectively managed by transoral robotic surgery via a minimally invasive approach. The operating costs can be relatively high although the advantages to patients seem to justify the procedure. Transoral robotic surgery can represent the definitive treatment in hypertrophy of the lingual tonsils. Objective: The purpose of this work was to assess the feasibility, safety, and outcomes of transoral robotic surgery for lingual tonsillar hypertrophy in adults with obstructive sleep apnea. Methods: Retrospective medical records of six patients who underwent tongue base resection using the da Vinci Surgical Robotic System from September, 2012 through December, 2013 in a tertiary care hospital were evaluated. Demographic data, preoperative and postoperative polysomnography and Epworth Sleepiness Scale (ESS) scores, robot docking time, operative and postoperative aspects including surgical time, amount of bleeding, and early and late complications were collected and analyzed. Results: All patients successfully underwent lingual tonsillectomy using the da Vinci Surgical system. Transnasal endotracheal entubation was performed in all patients and they were all extubated before leaving the operation room. No tracheotomies were performed perioperatively for airway management. The patients were discharged on the fifth postoperative day. Operative time, estimated blood loss, and postoperative complication profiles were within the expected and acceptable limits for lingual tonsillectomy. There was a statistically significant decrease in apnea hypopnea index (AHI) (mean AHI from 27.5 to 6.3) and ESS scores (from 14.1 to 7.1).

Lingual tonsillar hypertrophy: Cause of un-anticipated difficult intubation.

Lingual tonsillar hypertrophy: Cause of un-anticipated difficult intubation.

Airway Evaluation by Indirect Laryngoscopy in Patients With Lingual Tonsillar Hypertrophy

Introduction and objectivesPrevalence of the lingual tonsillar hypertrophy is unknown but it is believed that its presence is associated with the difficult airway. To investigate this, indirect laryngoscopy was performed on patients in the preoperative evaluation and this pathology was diagnosed. The relationship with difficulty of viewing the larynx, intubation and ventilation, under general anaesthesia and using direct laryngoscopy, was then studied. MethodsWe performed the demographic variable checks and tests for predicting difficult intubation (mouth opening, thyromental distance, cervical flexion-extension, neck thickness, and Mallampati test), in the preoperative step on 300 patients who were going to be submitted to general anaesthesia. We then performed indirect laryngoscopy on them using a 70° rigid laryngoscope to ascertain the frequency of appearance of lingual tonsillar hypertrophy. Next, under general anaesthesia, we carried out direct laryngoscopy to verify whether there was difficulty in viewing the larynx and intubation and ventilation. We then investigated the association of demographic predictors of difficult intubation, including indirect laryngoscopy, with the presence of this condition. ResultsPrevalence of lingual tonsillar hypertrophy was 2%. No relationship between the appearance of this entity and the difficulty of viewing the larynx, intubation and ventilation was found. Only indirect laryngoscopy was linked to the appearance of this pathology. ConclusionsLingual tonsillar hypertrophy is a relatively frequent disorder, whose presence is not usually associated with difficult airway.

Evaluación de la vía aérea mediante laringoscopia indirecta en pacientes con hipertrofia de la amígdala lingual

Introduction and objectivesPrevalence of the lingual tonsillar hypertrophy is unknown but it is believed that its presence is associated with the difficult airway. To investigate this, indirect laryngoscopy was performed on patients in the preoperative evaluation and this pathology was diagnosed. The relationship with difficulty of viewing the larynx, intubation and ventilation, under general anaesthesia and using direct laryngoscopy, was then studied. MethodsWe performed the demographic variable checks and tests for predicting difficult intubation (mouth opening, thyromental distance, cervical flexion-extension, neck thickness and Mallampati test), in the preoperative step on 300 patients who were going to be submitted to general anaesthesia. We then performed indirect laryngoscopy on them using a 70° rigid laryngoscope to ascertain the frequency of appearance of lingual tonsillar hypertrophy. Next, under general anaesthesia, we carried out direct laryngoscopy to verify whether there was difficulty in viewing the larynx and intubation and ventilation. We then investigated the association of demographic predictors of difficult intubation, including indirect laryngoscopy, with the presence of this condition. ResultsPrevalence of lingual tonsillar hypertrophy was 2%. No relationship between the appearance of this entity and the difficulty of viewing the larynx, intubation and ventilation was found. Only indirect laryngoscopy was linked to the appearance of this pathology. ConclusionsLingual tonsillar hypertrophy is a relatively frequent disorder, whose presence is not usually associated with difficult airway.

Difficult airway management in a case with lingual tonsil hypertrophy and temporo-mandibular joint partial ankylosis

Difficult airway management in a case with lingual tonsil hypertrophy and temporo-mandibular joint partial ankylosis

Effect of Obesity and Medical Comorbidities on Outcomes After Adjunct Surgery for Obstructive Sleep Apnea in Cases of Adenotonsillectomy Failure

To evaluate the effect of body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) and medical comorbidities on outcomes after lingual tonsillectomy and supraglottoplasty performed for obstructive sleep apnea syndrome (OSAS) caused by lingual tonsillar hypertrophy and occult laryngomalacia. Retrospective case review series Academic tertiary referral center Children with persistent OSAS after adenotonsillectomy who underwent surgery to correct obstruction at the level of the lingual tonsils and/or supraglottis identified on sleep endoscopy. All children underwent lingual tonsillectomy, supraglottoplasty, or both. Change in polysomnographic parameters, including apnea-hypopnea index (AHI), number of nighttime apneas, and lowest oxygen saturation level. We analyzed the medical records of 84 children with persistent OSAS after adenotonsillectomy who underwent either lingual tonsillectomy (n = 68), supraglottoplasty (n = 24) or both (n = 8). Compared with children with lingual tonsillar hypertrophy, children with occult laryngomalacia were younger, had lower BMI, and were more likely to have a medical comorbidity. Overall, both operations significantly improved the AHI; however, children with comorbidities had significantly higher postoperative AHIs after supraglottoplasty than those without, and overweight children had significantly higher postoperative AHIs after lingual tonsillectomy than those of normal weight. The BMI z-score and age had direct, though weak, correlations with postoperative AHI among all children undergoing either technique of adjunct airway surgery. Lingual tonsillar hypertrophy and occult laryngomalacia are 2 important causes of residual OSAS after adenotonsillectomy. However, they tend to affect distinct populations of children, and though appropriate surgical correction can improve AHI, cure rates are significantly worse for overweight children undergoing lingual tonsillectomy and for children with medical comorbidities undergoing supraglottoplasty.

A case‐control comparison of lingual tonsillar size in children with and without down syndrome

Lingual tonsillar hypertrophy is a common cause of persistent obstructive sleep apnea following adenotonsillectomy in the pediatric population and may be more prevalent in patients with Down syndrome (DS). We sought to quantify lingual tonsil size in pediatric DS patients and compare these findings to those of nonsyndromic children using cervical spine (c-spine) radiographs. Case control study. Retrospective review of c-spine radiographs from 105 pediatric DS patients and 89 age- and gender-matched non-DS controls was conducted. Films performed for possible airway compromise or trauma were excluded. Lingual tonsil size and narrowest lumen diameter of the nasopharynx, oropharynx, and hypopharynx were measured. Radiographically identifiable lingual tonsillar tissue was identified in 34% of children with DS and 30% of controls (P = .21); lingual tonsillar hypertrophy (≥10 mm) was seen in 5% and 0% respectively (P = .074). Nasopharyngeal diameter was smaller in patients with DS compared to controls (5.2 mm vs. 6.3 mm, P = .026), whereas lingual tonsil size was significantly larger in DS patients (2.1 mm vs. 0.8 mm, P = .0008). In multivariate analysis, lingual tonsil size was positively correlated with increasing age in the DS population (r = 0.38, P < .0001) but not in controls. Lingual tonsillar enlargement is more common in patients with DS than in controls, with an increased prevalence in older DS patients. C-spine radiographs are routinely carried out in these children and appear to be useful in identifying lingual tonsillar hypertrophy. Further trials should be carried out to compare c-spine findings and physical exam or magnetic resonance imaging to validate this method of evaluation.

Severe lingual tonsillar hypertrophy and the rationale supporting early use of wire-guided retrograde intubation

An expanding body of literature exists which describes the airway challenges and management options for lingual tonsillar hypertrophy (LTH). The use of retrograde intubation to secure a patient‘s airway in the setting of LTH has been previously unreported and should be considered early in the event of a cannot intubate, cannot ventilate scenario. A 55-year-old man, who had previously been described as an easy intubation, presented an unexpected cannot intubate, cannot ventilate scenario secondary to LTH. Various noninvasive airway maneuvers were attempted to restore ventilation without success. We describe the advantages of early use of wire-guided retrograde intubation as an alternative to a surgical airway for obtaining a secure airway in a patient with LTH, in whom noninvasive airway management maneuvers have failed. Multiple different noninvasive approaches to management of LTH have been previously described including the laryngeal tube, laryngeal mask airway, and fiberoptic bronchoscopy. Unfortunately, none of these noninvasive airway maneuvers successfully ventilated this patient and an invasive airway became necessary. Retrograde intubation is a less invasive alternative to the surgical airway with potentially less risk for complications. Retrograde intubation may be particularly effective in the setting of LTH as it may stent open an otherwise occluded airway and allow passage of an endotracheal tube. Skillful use of this technique should be considered early as a viable option in any case of unexpected difficult intubation due to LTH.

Persistent pediatric obstructive sleep apnea and lingual tonsillectomy

Objective To describe a new method and the indications for lingual tonsillectomy with endoscopy and coblation, and to document its utility for treating children with persistent obstructive sleep apnea after previous tonsillectomy and adenoidectomy. Study Design and Setting Case series with chart review in a tertiary pediatric medical center. Subjects and Methods Twenty-six patients aged 3 to 20 met the inclusion criteria of polysomnography-proven persistent obstructive sleep apnea after tonsillectomy and adenoidectomy, as well as diagnosis of lingual tonsillar hypertrophy made by flexible fiberoptic sleep endoscopy. Endoscopic-assisted coblation lingual tonsillectomies were performed between June 2005 and January 2008. Preoperative and postoperative nocturnal polysomnogram data were paired and analyzed statistically. Results Statistically significant reductions in the respiratory distress index (RDI) were seen when preoperative and postoperative data were compared (mean, 14.7 vs 8.1). There were similar reductions in the number of obstructive apneas and hypopneas. The mean minimum O 2 saturation did not change. Two patients in this series developed adhesions between the epiglottis and tongue base; there appeared to be no consequence for airway or feeding issues. Conclusion Endoscopic-assisted coblation lingual tonsillectomy is an effective technique for the treatment of lingual tonsillar hypertrophy causing persistent obstructive sleep apnea in some children.

Lingual Tonsillectomy for Persistent Pediatric Sleep Apnea

Objective 1) To describe our experience with a technique of lingual tonsillectomy using coblation with endoscopic visualization. 2) To document its utility for treating children with persistent sleep apnea after adenotonsillectomy who on sleep endoscopy have enlarged lingual tonsils and tongue base obstruction. Methods Retrospective cohort study in a tertiary pediatric medical center. Between 2005 and 2007, 20 patients (ages 3 -18), who had a previous adenotonsillectomy (T&amp;A) for obstructive sleep apnea (OSA), were diagnosed with persistent OSA by polysomnography (PSG). These children had both in-office unsedated fiberoptic laryngoscopy and dynamic anesthesia-assisted sleep fiberoptic laryngoscopy, both of which demonstrated lingual tonsillar hypertrophy contributing to tongue base obstruction of the hypopharynx. With a visually confirmed site of lesion, these children underwent endoscopic lingual tonsillectomy for treatment. Pre- and post-operative PSG data were paired and analyzed statistically. Results Statistically significant reductions in respiratory distress index (RDI) were observed when pre- and post-operative data were compared (mean 14.9 vs. 7.8, median 12.6 vs. 3.3). There were similar reductions in the number of apneas and hypopneas. The mean and median low O2 saturations did not change significantly. Conclusions Endoscopic lingual tonsillectomy is an effective technique for the treatment of lingual tonsillar hypertrophy causing persistent obstructive sleep apnea after T&amp;A. Anesthesia-assisted sleep endoscopy is key to diagnosing the obstructive contribution of the enlarged lingual tonsils. The combination of endoscopic access with the near bloodless technique for ablation of the lingual tonsils provides a consistently reproducible method of treating children with this uncommon problem.