Do patients literally swallow their tongue during anesthesia?

Patients Do Not Actually "Swallow Their Tongue" During Anesthesia

Patients do not literally swallow their tongue during anesthesia; rather, airway obstruction occurs when the relaxed tongue falls backward against the posterior pharyngeal wall due to loss of muscle tone.

Mechanism of Airway Obstruction During Anesthesia

Airway obstruction during anesthesia is a common concern, but the concept of "swallowing the tongue" is anatomically incorrect. Here's what actually happens:

What Really Occurs

• When a patient is under anesthesia, muscle tone decreases throughout the body, including the muscles that support the tongue and airway 1
• The tongue, which is attached at its base, relaxes and can fall backward against the posterior pharyngeal wall
• This posterior displacement of the tongue can partially or completely obstruct the airway 2
• The tongue does not detach or get swallowed into the esophagus or stomach

Scientific Evidence

• Ultrasound assessment studies have shown that tongue movement during anesthesia induction is minimal (not more than 8mm in the anterior tongue and 6mm in the posterior tongue) 3
• These movements are inconsistent in direction and do not support the notion that the tongue is "swallowed" 3

Managing Tongue-Based Airway Obstruction

When airway obstruction occurs due to posterior displacement of the tongue, several techniques can be employed:

Effective Maneuvers

• Chin lift: Consistently provides the most adequate airway opening by lifting the mandible forward, which pulls the tongue away from the posterior pharyngeal wall 2
• Jaw thrust: Effective technique that moves the mandible forward, bringing the tongue with it 2
• Head positioning: The "sniffing position" is recommended by the American Society of Anesthesiologists for optimal laryngeal visualization, aligning the oral, pharyngeal, and laryngeal axes 4

Airway Devices

• In cases of difficult ventilation, supraglottic airway devices can be used to maintain oxygenation 1
• Oral or nasopharyngeal airways can be inserted to create a channel for air to bypass the obstruction 1

Prevention and Risk Management

To prevent tongue-based airway obstruction during anesthesia:

• Proper patient positioning before induction (sniffing position or ramp position for obese patients) 4
• Maintaining appropriate depth of anesthesia to avoid excessive muscle relaxation 1
• Having airway equipment readily available, including supraglottic airways 1
• Following established difficult airway algorithms when complications arise 1

Special Considerations

• Children may be more susceptible to airway obstruction due to their relatively larger tongues compared to the size of their oropharynx 1
• During emergence from anesthesia, airway reflexes should be allowed to return before extubation to prevent obstruction 1
• Patients with obstructive sleep apnea or obesity have increased risk of tongue-based airway obstruction 1

The myth of "swallowing the tongue" persists in popular culture, but understanding the actual mechanism of airway obstruction during anesthesia is crucial for proper management and prevention of complications related to the loss of airway patency.