Images in Anesthesiology: Intraoral Lipomas

INTRAORAL lipomas can cause significant airway obstruction and lead to respiratory compromise. Additionally, they can grossly alter airway anatomy, making direct laryngoscopy challenging.¹  Oropharyngeal lipomas arising from the posterior pharynx or supraglottic region may present particular challenges for the anesthesiologist, given that they are not always obvious on preoperative evaluation.

This image shows an intraoral lipoma in a 9-day-old term neonate with a normal preoperative examination who underwent an uncomplicated general anesthetic with a supraglottic airway for magnetic resonance imaging. Following the anesthetic, stridor was noted and a bedside fiberoptic bronchoscopy identified intraoral lipomas. We hypothesize that the new onset stridor was due to the effect of residual anesthetic agent, causing increased pharyngeal collapsing forces and reduced neural compensation resulting in airway obstruction.²  The airway was subsequently secured with an awake nasal fiberoptic intubation.

Oral lipomas may complicate airway management. A supraglottic airway device may temporarily relieve airway obstruction, but may lead to lipoma swelling or displacement, and should not be used as a definitive form of airway management if the diagnosis is known. In severe cases, lipomas can produce a ball-valve effect, making ventilation extremely difficult. When large lipomas are recognized, the airway should be secured while maintaining spontaneous ventilation, or with the patient awake, to prevent airway compromise.¹  Neonates and infants with intraoral lipomas may be particularly prone to airway obstruction due to the size of their pharyngeal space.²  Intraoral lipomas rarely regress spontaneously, and should be addressed before elective anesthetics are performed. If completely resected, patients with oral lipomas have a good prognosis, though continued follow-up to assess for regrowth is warranted in the pediatric population.³