A 19-year-old woman presented for removal of her third molars and supernumerary teeth under general anesthesia. Her preoperative evaluation revealed a weight of 120.5 kg (265 lb) and a height of 167.6 cm (5 ft 6 in) with a body mass index of 42.8. Her past medical history included insomnia, for which she did not receive any medications. She had undergone a tonsillectomy at the age of 11 years with no surgical or anesthetic complications. She is a university student who denied any use of tobacco, alcohol, or recreational drugs. An intraoral soft tissue exam indicated no visible lesions on hard palate, soft palate, oropharynx, buccal mucosa, floor of the mouth, or dorsal and ventral surfaces of the tongue. She had a skeletal-dental class I relationship with malopposed, impacted third molars as the only obvious pathology. She had a Mallampati class III airway with a normal thryomental distance.
She presented on the morning for surgery with an escort and had nothing by mouth for 8 hours. Prior to inserting the intravenous catheter, she was monitored with intermittent noninvasive blood pressure at 5-minute intervals, continuous pulse oximetry, 3-lead electrocardiogram, pretracheal stethoscope, and a temperature probe. A 22-gauge intravenous catheter was placed in the right hand.
She was given 2.5 mg (0.02 mg/kg) of midazolam and 50 µg (0.41 µg/kg) of fentanyl, along with 0.2 mg (0.0017 mg/kg) glycopyrrolate prior to induction. She was preoxygenated by mask and was induced with 200 mg (1.66 mg/kg) of propofol and 100 µg (0.83 µg/kg) of remifentanil. She was easily ventilated manually via a full-face mask, which was confirmed with an end-tidal CO2 monitor and good breath sounds through the pretracheal stethoscope. A size 5 LMA ProSeal (LMA North America) laryngeal mask airway was inserted with little resistance and inflated with 35 mL air. Breath sounds and end-tidal CO2 confirmed placement with a small leak at 20 cm of H2O pressure. Anesthesia was maintained with 1 L/min O2, 1 L/min N2O, and 2% sevoflurane. Twenty minutes into the procedure, the dentist anesthesiologist noticed a leak in the LMA with some gurgling sounds through the pretracheal stethoscope. It was suspected that the LMA was dislodged and normal saline irrigation and possibly blood from the procedure had collected around the larynx. A few seconds after hearing the air leak, the patient had a laryngospasm and stopped ventilating. Positive pressure via the LMA was unsuccessful in breaking the laryngospasm. The LMA was removed, and the patient was suctioned aggressively with a Yankauer tonsillar suction (McKesson). A face mask was placed and another attempt to break the laryngospasm was unsuccessful with the use of positive pressure. When her oxygen saturation dropped to 87%, a decision was made to immediately intubate the trachea orally. The patient was then given 120 mg (1 mg/kg) of succinylcholine (Anectine, Sandoz Pharmaceuticals Inc) intravenously. After skeletal muscle fasciculation, the patient was easily mask ventilated with positive pressure oxygen. The attempt to intubate the trachea via direct laryngoscopy was unsuccessful on 2 attempts due to the lack of visualization of the glottis from an excess of hypertrophic tissue at the base of the tongue. Intubation was attempted with both MacIntosh #3 and #4 blades and a Miller #3 blade (SunMed Greenline). She was again easily mask ventilated until she started to breathe spontaneously. Her oxygen saturation quickly rose and stabilized at 100%, and she was hemodynamically stable with a blood pressure of 130/79 mm Hg and a pulse rate of 89 beats/min. Even though she could be ventilated, a decision was made to terminate the case and initiate a further work-up prior to the development of any additional anesthetic complications. During the recovery period, evaluation of the airway with the patient in a sitting position again demonstrated the lingual tonsil hypertrophy with the aid of a laryngeal mirror.