Do patients literally swallow their tongue during anesthesia?

Patients Do Not Swallow Their Tongue During Anesthesia

Patients do not literally swallow their tongue during anesthesia; this is a common misconception. The tongue may fall backward due to muscle relaxation, causing airway obstruction, but it is not actually swallowed 1.

Understanding Airway Obstruction During Anesthesia

When a patient is under anesthesia, several physiological changes occur that can affect the airway:

1. Muscle Relaxation: General anesthesia causes relaxation of pharyngeal muscles, including those that support the tongue

2. Posterior Displacement: The tongue can fall backward (posterior displacement) toward the pharyngeal wall due to gravity and loss of muscle tone 2

3. Airway Obstruction: This posterior displacement can partially or completely obstruct the airway, but this is not "swallowing" the tongue 1

Evidence from Imaging Studies

Ultrasound assessment of tongue position during anesthesia induction has shown that:

• Tongue movements during anesthesia induction are minimal (not more than 8mm in the anterior tongue and 6mm in the posterior tongue)
• The movements detected do not suggest that the tongue is a major cause of airway obstruction 1

Airway Management Techniques

To address potential airway obstruction caused by posterior displacement of the tongue, several techniques are recommended:

Head Positioning

• Sniffing Position: The American Society of Anesthesiologists recommends this position for optimal laryngeal visualization, which aligns the oral, pharyngeal, and laryngeal axes 3
• Ramp Position: For obese patients, positioning with the external auditory meatus at the level of the sternal notch 3

Manual Techniques

• Chin Lift: Research indicates this technique provides the most consistently adequate airway when addressing tongue-based obstruction 4
• Jaw Thrust: Forward displacement of the mandible pulls the tongue forward, opening the airway 4

Airway Devices

• Oropharyngeal Airways: Prevent the tongue from falling back against the posterior pharyngeal wall
• Supraglottic Airways: Such as laryngeal mask airways (LMAs) can be used to maintain airway patency 2
• Endotracheal Tubes: Provide definitive airway protection when indicated 2

Special Considerations During Extubation

The Difficult Airway Society guidelines highlight that extubation is a critical period when airway complications can occur:

• Approximately one-third of major airway complications occur during emergence or recovery 2
• Death or brain injury is more common in claims associated with extubation and recovery than those occurring at induction 2
• Patients with obesity or obstructive sleep apnea are at higher risk for complications during extubation 2

Practical Recommendations

1. Anticipate Potential Difficulties: Assess risk factors for airway obstruction before anesthesia

2. Position Properly: Use appropriate positioning (sniffing or ramp position) to optimize airway alignment 3

3. Have Airway Equipment Ready: Ensure availability of appropriate airway management tools

4. Monitor Closely During Emergence: The transition from controlled to uncontrolled situations during extubation requires vigilance 2

5. Consider Special Populations: Patients with obesity, obstructive sleep apnea, or difficult airways require additional attention during both induction and emergence 2

In summary, while airway obstruction due to posterior displacement of the tongue is a real concern during anesthesia, patients do not literally "swallow" their tongue. Understanding proper airway management techniques is essential for preventing and addressing potential airway complications.