Ann Otol Rhinal Laryngal99: 1990
SEVERE UPPER AIRWAY OBSTRUCTION IN CHILDREN SECONDARY TO LINGUAL TONSIL HYPERTROPHY J. LINDHE GUARISCO, MD STEVEN C. LITTLEWOOD, MD R. BRENT BUTCHER III, MD NEW ORLEANS, LOUISIANA
Lingual tonsil hypertrophy inchildren isa rarely reported disorder. Two cases ofsevere upper airway obstruction inpediatric patients secondary to marked lingual tonsil enlargement are reported. Both children were effectively treated with lingual tonsillectomy. The surgical technique, using an insulated Bovie tip, is described. KEY WORDS - lingual tonsils, stricture, upper airway obstruction. INTRODUCTION
chea and bronchi, the bronchoscope was exchanged for an endotracheal tube. Specimens for culture and biopsy were taken, and the patient was transferred to the pediatric intensive care unit.
Hypertrophy of the adenoid and palatine tonsils is a well-recognized cause of chronic upper airway obstruction in children. 1 Inflammation of these tissues may also lead to significant acute upper airway obstruction." It is for the most part unrecognized that the lingual tonsils may be the cause of both acute and chronic obstruction in pediatric patients. In this paper, we report two cases of severe upper airway obstruction secondary to lingual tonsil enlargement in children. The limited literature regarding lingual tonsil hypertrophy leading to airway obstruction is also reviewed, and recommendations regarding the management of these patients are made.
Intravenous ampicillin sodium and dexamethasone sodium phosphate were given every 6 hours, and the patient was extubated after 48 hours. The blood cultures and Monospot test on blood drawn on admission were negative for pathogens. The biopsy showed nonspecific inflammation, and the surface cultures grew multiple organisms. Results of a thyroid scan were normal, and flexible fiberoptic endoscopy confirmed the presence of markedly hypertrophic lingual tonsils. The patient was discharged after 5 days and returned for lingual tonsillectomy 3 weeks later. A nasotracheal tube was inserted after the induction of general anesthesia. Insertion of the tube was more difficult than usual because of the markedly enlarged lingual tonsils. A Jennings mouth gag, a 3-0 silk traction suture through the tongue, and a Weeder tongue depressor provided excellent exposure of the huge lingual tonsils (Fig 1A). The lingual tonsils were removed by grasping the tissue with a curved Allis clamp and cutting just above the fascia at the base of the tongue. An insulated Bovie tip with the electrocautery unit set on coagulation was used as a cutting instrument (Fig 1B). A Yankauer suction tip was used to evacuate smoke during the procedure. Blood loss was minimal.
CASE REPORTS
Case 1. A 9-year-old boy with Down syndrome presented to the emergency room with acute stridor. At bedtime he had been breathing normally, but 2 hours later he was found sitting leaning forward, stridorous, and in moderate distress. The past medical history was remarkable for multiple episodes of "croup" managed by outpatient treatment at another institution and an adenotonsillectomy at age 7. The patient was combative and anxious, with severe inspiratory stridor. His vital signs revealed a temperature of 38°C orally, a pulse of 160 beats per minute, and a respiratory rate of 36 breaths per minute. A capillary blood gas measurement revealed a pH of 7.27, a carbon dioxide of 57, and a P02 of 56. After immediate transport to the operating room, inhalation anesthesia was induced during spontaneous respiration, and laryngoscopy was performed. Extremely hypertrophic lingual tonsil tissue was noted, extending into the valleculae and displacing the epiglottis posteriorly and producing a near-total obstruction of the glottis. The epiglottis and larynx were normal. A rigid ventilating bronchoscope was passed, and muscle relaxants were administered. After examination of the tra-
1
Following the removal of a 1 / 2 x 2 x 3-cm mass of lingual tonsil, the airway was clearly unobstructed (Fig 1C,D). The patient recovered uneventfully, and he has had no further episodes of airway obstruction in the 18 months following the operation. Case 2. A 5-year-old boy was referred for evaluation of obstructive sleep apnea. His parents described a lifetime history of daytime mouth breathing and sleep disturbances with loud snoring, com-
From the Department of Ear, Nose and Throat, Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, Louisiana. REPRINTS - J. Lindhe Guarisco, MD, Ochsner Clinic, 1514 Jefferson Hwy, New Orleans, LA 70121.
621
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 10, 2015
622
Guarisco et al, Lingual Tonsil Hypertrophy
'2 ,1,
h
J ",L,
1
4
~~'.Kr~L~_.
/ h_L!,~
c Fig 1. (Case 1) A) Large obstructing lingual tonsils. B) Insulated Bovie tip used for lingual tonsillectomy. C) Mass of lingual tonsil tissue (PI, x 2 x 3 ern) removed. D) Airway following removal of lingual tonsils.
plete obstruction with sternal retractions, and orthopnea. They specifically noted that he was unable to sleep without being propped up with at least two pillows. Examination revealed mouth breathing and hyponasal speech. His palatine tonsils were moderate in size and nonobstructing. Flexible fiberoptic endoscopy revealed only a moderately enlarged adenoid pad. Huge lingual tonsils, producing near-total obstruction of the hypopharynx, were also noted (Fig 2A). The patient returned for adenoidectomy and lingual tonsillectomy a few weeks later. Significant difficulty in maintaining mask ventilation was encountered during the induction of general anesthesia. Nasotracheal intubation was also difficult, because the extremely enlarged lingual tonsils totally obscured the epiglottis and glottis (Fig 2B). A 2 X 2 1/ 2 x 4-cm lingual tonsil pad was removed with an insulated Bovie tip (Fig 2C). The previously obstructed laryngeal structures were immediately visible (Fig 2D). The nasotracheal tube was then exchanged for an orotracheal tube, and a routine adenoidectomy was performed. The patient has been followed up for 6 months
postoperatively and is completely relieved of his symptoms. He is now able to sleep lying flat. Flexible fiberoptic examination of the larynx revealed excellent healing and a widely patent hypopharynx with clearly visible supraglottic and glottic structures (Fig 2E). DISCUSSION
Hypertrophy of the adenoid and palatine tonsils has been implicated in a spectrum of severe and even life-threatening upper airway disease. Attention has been focused on its role in obstructive sleep apnea in adults and in children and the efficacy of adenotonsillectomy in eliminating or significantly reducing the severity of symptoms." The lingual tonsils, however, are for the most part neglected in studies of these topics. Lingual tonsil enlargement most commonly produces symptoms of pain, dysphagia, otalgia, or the sensation of a lump in the throat; and occasional reports of lingual tonsillectomy for these complaints may be found." Only a few reports focus on airway symptoms caused by lingual tonsils. Joseph et al" reported on lingual tonsillectomy performed in 11 patients, most with symptoms of dysphagia or recurrent infection; one
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 10, 2015
Guarisco et al, Lingual Tonsil Hypertrophy
623
II em 1
6
Ip.C
0
Fig 2. (Case 2) A) Extremely large lingual tonsils as viewed through flexible scope. Small arrow - oropharyngeal wall, large arrow - obstructing lingual tonsils. B) Airway following intubation. C) Mass of lingual tonsil tissue (2 x 2'/, x 4 cm) removed. D) Airway following removal of lingual tonsils. E) Six-weeks' postoperative appearance of airway as viewed through flexible scope.
adult patient presented with stridor and sleep disturbances that resolved after tonsillectomy. Olsen et al" described a case of a 13-year-old boy with obstructive sleep apnea relieved by lingual tonsillectomy. Johnson et al" reported an adult patient with acute purulent lingual tonsillitis and bleeding from this area who developed complete airway obstruction during induction of general anesthesia, necessitating an emergency tracheotomy. Medical treatment allowed decannulation; no further treatment was described.
The patient in case 1 developed acute upper airway obstruction secondary to sudden inflammation of his chronically enlarged lingual tonsils. This is the first report of a pediatric patient developing life-threatening obstruction secondary to a lingual tonsil disorder. His recurrent episodes of "croup," most likely due to recurrent lingual tonsillitis with airway compromise, resolved after lingual tonsillectomy. Prior adenotonsillectomy had not relieved his symptoms, and in fact it has been noted by various authors that lingual tonsil disease is noted most
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 10, 2015
624
Guarisco et al, Lingual Tonsil Hypertrophy
commonly in patients who have undergone tonsillectomy." Whether this anecdotal finding represents compensatory hypertrophy or a general predisposition to growth of tonsil tissue is unknown. The child in case 2 had classic obstructive apnea secondary to chronically enlarged lingual tonsils. Although no sleep studies were performed, the history and physical findings clearly confirmed the diagnosis. The flexible fiberoptic scope is extremely useful in evaluating patients with obstruction symptoms, and in case 2 the diagnosis was made with this instrument. On the basis of the literature reviewed for this report, obstructive sleep apnea in children secondary to lingual tonsil hypertrophy is rare. Only two other case reports were located in a 20year retrospective search of the literature. 5.8 Various techniques for removing the lingual tonsils have been proposed. Dissection and snare, adenoid curettes, cryosurgery, and the carbon dioxide laser have all been advocated by different authors. 7.9.10 The Bovie electrocautery unit with an insulated tip was used in the patients presented here. With the unit on the coagulation setting, rapid and bloodless dissection was possible. The lingual tonsil tissue was well delineated from the tongue musculature by a clearly evident fascial plane in both children. Nasotracheal intubation, a Jennings mouth gag, a heavy silk retraction suture through the tip of the tongue, and a Weeder tongue depressor aided in exposure. The use of a curved Allis clamp to grasp
the lingual tonsils and draw them anteriorly allowed ideal visualization and easy removal. No difficulties with postoperative swelling were encountered, and the increased airway diameter after lingual tonsil removal greatly outweighed the moderate degree of swelling and edema noted. As a precaution, intravenous dexamethasone sodium phosphate at a dose of 12 mg preoperatively and 6 mg every 6 hours for two doses postoperatively was prescribed for each child. The postoperative course of both patients was similar to that following routine adenotonsillectomy. SUMMARY
In summary, lingual tonsil enlargement may produce severe airway compromise in children. Chronically enlarged tissue may lead to classic obstructive sleep apnea, and acute inflammation may lead to life-threatening obstruction. The routine use of the flexible fiberoptic scope to examine the upper airway in children with obstructive symptoms facilitates clear visualization of the lingual tonsils. Indirect mirror examination is not as useful, as protrusion of the tongue does not allow the examiner to clearly recognize the relative size of the lingual tonsils. The use of the Bovie cautery device with an insulated tip allows a rapid, bloodless, anatomic dissection of the lingual tonsils. Finally, lingual tonsillectomy is a relatively safe and effective procedure in the treatment of upper airway obstruction secondary to lingual tonsil hypertrophy in children.
REFERENCES 1. Menashe VD, Farrehi C, Miller M. Hypoventilation and cor pulmonale due to chronic upper airway obstruction. J Pediatr 1965;66: 198-203.
6. Johnson MA, Mehdiabadi AJ, Ruff A. Infection and hypertrophy of the lingual tonsil as a cause of airway obstruction. Tex Med 1980;82:29-31.
2. Spector S, Bautista AG. Respiratory obstruction caused by acute tonsillitis and acute adenoiditis. NY State J Med 1956;56: 2118-20.
7. Jesberg N. Chronic, hypertrophic lingual tonsillitis. Arch OtolaryngoI1956;64:3-13.
3. Potsic WP, Pasquariello PS, Baranak CC, Marsh RR, Miller LM. Relief of upper airway obstruction by adenotonsillectomy. Otolaryngol Head Neck Surg 1986;94:476-80.
8. Phillips DE, Rogers JH. Down's syndrome with lingual tonsil hypertrophy producing sleep apnea. J Laryngol Otol 1988; 102:1054-5.
4. Joseph M, Reardon E, Goodman M. Lingual tonsillectomy, a treatment for inflammatory lesions of the lingual tonsil. Laryngoscope 1984;94:179-83.
9. Principato JJ. Cryosurgical treatment of the lymphoid tissue of Waldeyer's ring. Otolaryngol Clin North Am 1987;20: 365-70.
5. Olsen KD, Suh KW, Staats BA. Surgically correctable causes of sleep apnea syndrome. Otolaryngol Head Neck Surg 1981;89:726-31.
10. Krespi YP, Har-El G, Levine TM, Ossoff RH, Wurster CF, Paulsen JW. Laser lingual tonsillectomy. Laryngoscope 1989;99:131-5.
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 10, 2015
SEVERE UPPER AIRWAY OBSTRUCTION IN CHILDREN SECONDARY TO LINGUAL TONSIL HYPERTROPHY J. LINDHE GUARISCO, MD STEVEN C. LITTLEWOOD, MD R. BRENT BUTCHER III, MD NEW ORLEANS, LOUISIANA
Lingual tonsil hypertrophy inchildren isa rarely reported disorder. Two cases ofsevere upper airway obstruction inpediatric patients secondary to marked lingual tonsil enlargement are reported. Both children were effectively treated with lingual tonsillectomy. The surgical technique, using an insulated Bovie tip, is described. KEY WORDS - lingual tonsils, stricture, upper airway obstruction. INTRODUCTION
chea and bronchi, the bronchoscope was exchanged for an endotracheal tube. Specimens for culture and biopsy were taken, and the patient was transferred to the pediatric intensive care unit.
Hypertrophy of the adenoid and palatine tonsils is a well-recognized cause of chronic upper airway obstruction in children. 1 Inflammation of these tissues may also lead to significant acute upper airway obstruction." It is for the most part unrecognized that the lingual tonsils may be the cause of both acute and chronic obstruction in pediatric patients. In this paper, we report two cases of severe upper airway obstruction secondary to lingual tonsil enlargement in children. The limited literature regarding lingual tonsil hypertrophy leading to airway obstruction is also reviewed, and recommendations regarding the management of these patients are made.
Intravenous ampicillin sodium and dexamethasone sodium phosphate were given every 6 hours, and the patient was extubated after 48 hours. The blood cultures and Monospot test on blood drawn on admission were negative for pathogens. The biopsy showed nonspecific inflammation, and the surface cultures grew multiple organisms. Results of a thyroid scan were normal, and flexible fiberoptic endoscopy confirmed the presence of markedly hypertrophic lingual tonsils. The patient was discharged after 5 days and returned for lingual tonsillectomy 3 weeks later. A nasotracheal tube was inserted after the induction of general anesthesia. Insertion of the tube was more difficult than usual because of the markedly enlarged lingual tonsils. A Jennings mouth gag, a 3-0 silk traction suture through the tongue, and a Weeder tongue depressor provided excellent exposure of the huge lingual tonsils (Fig 1A). The lingual tonsils were removed by grasping the tissue with a curved Allis clamp and cutting just above the fascia at the base of the tongue. An insulated Bovie tip with the electrocautery unit set on coagulation was used as a cutting instrument (Fig 1B). A Yankauer suction tip was used to evacuate smoke during the procedure. Blood loss was minimal.
CASE REPORTS
Case 1. A 9-year-old boy with Down syndrome presented to the emergency room with acute stridor. At bedtime he had been breathing normally, but 2 hours later he was found sitting leaning forward, stridorous, and in moderate distress. The past medical history was remarkable for multiple episodes of "croup" managed by outpatient treatment at another institution and an adenotonsillectomy at age 7. The patient was combative and anxious, with severe inspiratory stridor. His vital signs revealed a temperature of 38°C orally, a pulse of 160 beats per minute, and a respiratory rate of 36 breaths per minute. A capillary blood gas measurement revealed a pH of 7.27, a carbon dioxide of 57, and a P02 of 56. After immediate transport to the operating room, inhalation anesthesia was induced during spontaneous respiration, and laryngoscopy was performed. Extremely hypertrophic lingual tonsil tissue was noted, extending into the valleculae and displacing the epiglottis posteriorly and producing a near-total obstruction of the glottis. The epiglottis and larynx were normal. A rigid ventilating bronchoscope was passed, and muscle relaxants were administered. After examination of the tra-
1
Following the removal of a 1 / 2 x 2 x 3-cm mass of lingual tonsil, the airway was clearly unobstructed (Fig 1C,D). The patient recovered uneventfully, and he has had no further episodes of airway obstruction in the 18 months following the operation. Case 2. A 5-year-old boy was referred for evaluation of obstructive sleep apnea. His parents described a lifetime history of daytime mouth breathing and sleep disturbances with loud snoring, com-
From the Department of Ear, Nose and Throat, Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, Louisiana. REPRINTS - J. Lindhe Guarisco, MD, Ochsner Clinic, 1514 Jefferson Hwy, New Orleans, LA 70121.
621
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 10, 2015
622
Guarisco et al, Lingual Tonsil Hypertrophy
'2 ,1,
h
J ",L,
1
4
~~'.Kr~L~_.
/ h_L!,~
c Fig 1. (Case 1) A) Large obstructing lingual tonsils. B) Insulated Bovie tip used for lingual tonsillectomy. C) Mass of lingual tonsil tissue (PI, x 2 x 3 ern) removed. D) Airway following removal of lingual tonsils.
plete obstruction with sternal retractions, and orthopnea. They specifically noted that he was unable to sleep without being propped up with at least two pillows. Examination revealed mouth breathing and hyponasal speech. His palatine tonsils were moderate in size and nonobstructing. Flexible fiberoptic endoscopy revealed only a moderately enlarged adenoid pad. Huge lingual tonsils, producing near-total obstruction of the hypopharynx, were also noted (Fig 2A). The patient returned for adenoidectomy and lingual tonsillectomy a few weeks later. Significant difficulty in maintaining mask ventilation was encountered during the induction of general anesthesia. Nasotracheal intubation was also difficult, because the extremely enlarged lingual tonsils totally obscured the epiglottis and glottis (Fig 2B). A 2 X 2 1/ 2 x 4-cm lingual tonsil pad was removed with an insulated Bovie tip (Fig 2C). The previously obstructed laryngeal structures were immediately visible (Fig 2D). The nasotracheal tube was then exchanged for an orotracheal tube, and a routine adenoidectomy was performed. The patient has been followed up for 6 months
postoperatively and is completely relieved of his symptoms. He is now able to sleep lying flat. Flexible fiberoptic examination of the larynx revealed excellent healing and a widely patent hypopharynx with clearly visible supraglottic and glottic structures (Fig 2E). DISCUSSION
Hypertrophy of the adenoid and palatine tonsils has been implicated in a spectrum of severe and even life-threatening upper airway disease. Attention has been focused on its role in obstructive sleep apnea in adults and in children and the efficacy of adenotonsillectomy in eliminating or significantly reducing the severity of symptoms." The lingual tonsils, however, are for the most part neglected in studies of these topics. Lingual tonsil enlargement most commonly produces symptoms of pain, dysphagia, otalgia, or the sensation of a lump in the throat; and occasional reports of lingual tonsillectomy for these complaints may be found." Only a few reports focus on airway symptoms caused by lingual tonsils. Joseph et al" reported on lingual tonsillectomy performed in 11 patients, most with symptoms of dysphagia or recurrent infection; one
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 10, 2015
Guarisco et al, Lingual Tonsil Hypertrophy
623
II em 1
6
Ip.C
0
Fig 2. (Case 2) A) Extremely large lingual tonsils as viewed through flexible scope. Small arrow - oropharyngeal wall, large arrow - obstructing lingual tonsils. B) Airway following intubation. C) Mass of lingual tonsil tissue (2 x 2'/, x 4 cm) removed. D) Airway following removal of lingual tonsils. E) Six-weeks' postoperative appearance of airway as viewed through flexible scope.
adult patient presented with stridor and sleep disturbances that resolved after tonsillectomy. Olsen et al" described a case of a 13-year-old boy with obstructive sleep apnea relieved by lingual tonsillectomy. Johnson et al" reported an adult patient with acute purulent lingual tonsillitis and bleeding from this area who developed complete airway obstruction during induction of general anesthesia, necessitating an emergency tracheotomy. Medical treatment allowed decannulation; no further treatment was described.
The patient in case 1 developed acute upper airway obstruction secondary to sudden inflammation of his chronically enlarged lingual tonsils. This is the first report of a pediatric patient developing life-threatening obstruction secondary to a lingual tonsil disorder. His recurrent episodes of "croup," most likely due to recurrent lingual tonsillitis with airway compromise, resolved after lingual tonsillectomy. Prior adenotonsillectomy had not relieved his symptoms, and in fact it has been noted by various authors that lingual tonsil disease is noted most
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 10, 2015
624
Guarisco et al, Lingual Tonsil Hypertrophy
commonly in patients who have undergone tonsillectomy." Whether this anecdotal finding represents compensatory hypertrophy or a general predisposition to growth of tonsil tissue is unknown. The child in case 2 had classic obstructive apnea secondary to chronically enlarged lingual tonsils. Although no sleep studies were performed, the history and physical findings clearly confirmed the diagnosis. The flexible fiberoptic scope is extremely useful in evaluating patients with obstruction symptoms, and in case 2 the diagnosis was made with this instrument. On the basis of the literature reviewed for this report, obstructive sleep apnea in children secondary to lingual tonsil hypertrophy is rare. Only two other case reports were located in a 20year retrospective search of the literature. 5.8 Various techniques for removing the lingual tonsils have been proposed. Dissection and snare, adenoid curettes, cryosurgery, and the carbon dioxide laser have all been advocated by different authors. 7.9.10 The Bovie electrocautery unit with an insulated tip was used in the patients presented here. With the unit on the coagulation setting, rapid and bloodless dissection was possible. The lingual tonsil tissue was well delineated from the tongue musculature by a clearly evident fascial plane in both children. Nasotracheal intubation, a Jennings mouth gag, a heavy silk retraction suture through the tip of the tongue, and a Weeder tongue depressor aided in exposure. The use of a curved Allis clamp to grasp
the lingual tonsils and draw them anteriorly allowed ideal visualization and easy removal. No difficulties with postoperative swelling were encountered, and the increased airway diameter after lingual tonsil removal greatly outweighed the moderate degree of swelling and edema noted. As a precaution, intravenous dexamethasone sodium phosphate at a dose of 12 mg preoperatively and 6 mg every 6 hours for two doses postoperatively was prescribed for each child. The postoperative course of both patients was similar to that following routine adenotonsillectomy. SUMMARY
In summary, lingual tonsil enlargement may produce severe airway compromise in children. Chronically enlarged tissue may lead to classic obstructive sleep apnea, and acute inflammation may lead to life-threatening obstruction. The routine use of the flexible fiberoptic scope to examine the upper airway in children with obstructive symptoms facilitates clear visualization of the lingual tonsils. Indirect mirror examination is not as useful, as protrusion of the tongue does not allow the examiner to clearly recognize the relative size of the lingual tonsils. The use of the Bovie cautery device with an insulated tip allows a rapid, bloodless, anatomic dissection of the lingual tonsils. Finally, lingual tonsillectomy is a relatively safe and effective procedure in the treatment of upper airway obstruction secondary to lingual tonsil hypertrophy in children.
REFERENCES 1. Menashe VD, Farrehi C, Miller M. Hypoventilation and cor pulmonale due to chronic upper airway obstruction. J Pediatr 1965;66: 198-203.
6. Johnson MA, Mehdiabadi AJ, Ruff A. Infection and hypertrophy of the lingual tonsil as a cause of airway obstruction. Tex Med 1980;82:29-31.
2. Spector S, Bautista AG. Respiratory obstruction caused by acute tonsillitis and acute adenoiditis. NY State J Med 1956;56: 2118-20.
7. Jesberg N. Chronic, hypertrophic lingual tonsillitis. Arch OtolaryngoI1956;64:3-13.
3. Potsic WP, Pasquariello PS, Baranak CC, Marsh RR, Miller LM. Relief of upper airway obstruction by adenotonsillectomy. Otolaryngol Head Neck Surg 1986;94:476-80.
8. Phillips DE, Rogers JH. Down's syndrome with lingual tonsil hypertrophy producing sleep apnea. J Laryngol Otol 1988; 102:1054-5.
4. Joseph M, Reardon E, Goodman M. Lingual tonsillectomy, a treatment for inflammatory lesions of the lingual tonsil. Laryngoscope 1984;94:179-83.
9. Principato JJ. Cryosurgical treatment of the lymphoid tissue of Waldeyer's ring. Otolaryngol Clin North Am 1987;20: 365-70.
5. Olsen KD, Suh KW, Staats BA. Surgically correctable causes of sleep apnea syndrome. Otolaryngol Head Neck Surg 1981;89:726-31.
10. Krespi YP, Har-El G, Levine TM, Ossoff RH, Wurster CF, Paulsen JW. Laser lingual tonsillectomy. Laryngoscope 1989;99:131-5.
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 10, 2015
