What is the treatment for large lingual tonsils?

Treatment of Large Lingual Tonsils

For children with lingual tonsillar hypertrophy causing obstructive sleep apnea, lingual tonsillectomy is recommended and demonstrates significant improvement in OSA severity, with 61% of patients achieving AHI <5 events/hour. 1

Diagnostic Confirmation Required

Before proceeding with treatment, confirm the diagnosis through appropriate imaging:

• Awake flexible laryngoscopy or drug-induced sleep endoscopy (DISE) are the preferred diagnostic methods to document >50% airway obstruction at the tongue base 1
• Alternative imaging includes plain neck X-rays, computed tomography, or cine MRI, though these are less commonly used 1
• Lingual tonsillar hypertrophy is particularly common in children with Down syndrome and those with prior adenotonsillectomy 1

Primary Treatment Approach

For Pediatric Patients with OSA

Lingual tonsillectomy is the definitive treatment when lingual tonsillar hypertrophy causes persistent OSA:

• Performed transorally using radiofrequency ablation, suction cautery, or microdebridement 1
• Can be performed as stand-alone procedure or combined with midline glossectomy 1
• Reduces mean AHI by 6.6 events/hour (95% CI: 4.7-8.5 events/hour) 1
• 26% of patients achieve complete resolution (AHI <1 event/hour), though confidence interval crosses zero 1

For Adult Patients with OSA

The evidence for adults is more nuanced and depends on the clinical context:

• Lingualplasty (extended posterior and lateral tongue excision with lingual tonsil removal) is more effective than laser midline glossectomy alone for patients with CPAP intolerance and documented tongue base/lingual tonsillar obstruction 1
• Requires preoperative tracheotomy and carries 27% perioperative complication rate, though no long-term complications were reported 1

Important caveat: Isolated lingual tonsillectomy combined with extended uvulopalatal flap showed no effect on OSA in one study of non-obese adults, whereas the same palatal procedure combined with midline glossectomy achieved 83% success 1

Expected Adverse Events

Be prepared to manage these complications:

• Airway edema (19% in one pediatric series) - most common immediate complication 1
• Minor airway obstruction requiring supplemental oxygen (28%) 1
• Adhesions between epiglottis and tongue base (8%) 1
• Bleeding, voice changes, dysphagia, and dehydration (3-8% each) 1
• Emergency department visits and hospitalizations occur but are uncommon 1
• No infections, hemorrhage requiring intervention, or reintubations reported in the largest pediatric series 1

For Non-OSA Indications

When lingual tonsillar hypertrophy causes symptoms other than OSA:

• Laser lingual tonsillectomy is effective for chronic inflammation or hyperplasia causing globus sensation, dysphagia, or chronic throat symptoms 2
• Well-tolerated with no significant operative complications in a series of 82 patients 2
• Coblation-assisted lingual tonsillectomy successfully treats dysphagia secondary to tongue base hypertrophy by removing mechanical interference with laryngeal elevation 3

Critical Pitfalls to Avoid

• Do not perform isolated lingual tonsillectomy in adults with OSA - the evidence suggests it is ineffective when not combined with other tongue base reduction techniques 1
• Do not underestimate airway risk - severe lingual tonsillar hypertrophy can cause unanticipated difficult airway with face mask ventilation difficulties (29.6%), difficult intubation (89.1%), and failed intubation (21.7%) 4
• In known severe cases requiring anesthesia for other procedures, strongly consider awake intubation and have emergency front of neck access immediately available 4
• Radiofrequency ablation of tongue base as isolated procedure cannot be recommended due to insufficient evidence and inconsistent long-term results 1, 5

Alternative Approaches for Refractory Cases

If lingual tonsillectomy alone is insufficient or in complex multilevel obstruction:

• Tongue base reduction with hyoepiglottoplasty achieved 100% success at 6 months in severe OSA with macroglossia, though 30% had temporary swallowing abnormalities 1
• Multilevel surgery combining palatal and tongue base procedures may be considered as salvage therapy when CPAP fails 5
• Glossopexia has no role due to poor outcomes and severe complications including tongue immobility, taste disturbances, and mediastinal infections 1