Fig. 3. Endoscopic view of the epiglottis and vallecula of six patients awake and breathing spontaneously. Group 1 : (A ) Patient 15: This patient had a history of failed intubation and difficult mask ventilation. Massive hypertrophy of lingual tonsil covers the tip and lateral borders of the epiglottis. Group 2 : (B ) Patient 24: Failed rigid intubation resulted in an unrecognized esophageal tear but was intubated with fiberscope for loop ileostomy. The patient returned later that day for repair of the esophageal tear. Awake fiberoptic intubation showed massive enlargement of the lingual tonsils extended to the tip and lateral borders of the epiglottis. Group 3 : (C ) Patient 26: Ten years ago when the patient weighed 85 kg, she could not be intubated and suffered cardiac arrest. A 6-mm tube was placed blindly into the trachea followed by successful resuscitation. The massive enlargement of the lingual tonsils covers the lateral borders and the tip of the epiglottis. (D ) Patient 27: Previous anesthesia 8 months ago for thoracotomy was cancelled after 90 min of failed intubation attempts. Face mask ventilation was also impossible from the beginning and a size 4 LMA was used to ventilate the lungs between intubation attempts. Awake fiberoptic orotracheal intubation was performed for an orthopedic procedure. Massive lingual tonsils with redundant pharnygeal tissues pushed the epiglottis down against the posterior pharyngeal wall. (E ) Patient 29: Scheduled for gastric bypass revision. Mask ventilation was difficult with both oral and nasal airways in place. Large lingual tonsils occupy the entire vallecula extending down to the tip and lateral edges of the epiglottis. Group 4 : (F ) Patient 33: The lobulated mass represents lingual tonsil hyperplasia (LTH). ENT consultation confirmed LTH and ruled out hemangioma.