Curved blade laryngoscopy, whether with a conventional direct blade or video laryngoscope (with a Macintosh design or hyperangulated shape), depends on indirect elevation of the epiglottis. The tip of the blade sits in the vallecula, with the epiglottis lifted upward by pressure on the underlying hyoepiglottic ligament. The epiglottis is positioned between the line of sight (video or direct) and the glottic opening.

In my cadaver lab in Baltimore, as well as in emergency airways, I am increasingly encountering the “omega-shaped epiglottis.” A long, curvilinear epiglottis with an omega shape has commonly been reported in children, but I have noticed it is quite common in obese adult patients as well.

An omega-shaped epiglottis creates multiple challenges for intubation. The epiglottis may be difficult to elevate, precluding any sighting of the glottis. Passing a tube or bougie through a long omega-shaped epiglottis is akin to passing a thread through a needle. The operator cannot see if the tip of a tube or bougie is actually going into the glottis.

Difficulties of tube delivery and laryngeal exposure are especially problematic in obese patients. Many of these patients require continuous positive airway pressure before and during induction to maintain oxygenation, and they require a “one and done” approach to intubation to avoid desaturation. They have short safe apnea times and are often difficult to mask ventilate.

Emergency airway providers should anticipate this problem, especially in obese patients, and have a clear plan for tackling the challenge.

Techniques for handling the omega-shaped epiglottis include:

1 Using bimanual laryngoscopy. This changes how the tip of the blade interacts with the hyoepiglottic ligament. This is best done by operators applying their right hand to the neck during direct or video laryngoscopy. Occasionally, assistants are needed to maintain pressure at the proper location because the view can deteriorate when pressure is released.

2 Using a bougie to “thread the needle” (see Figure 1). This also allows confirmation of placement within the trachea as the bougie interacts with the tracheal rings.

3 Lifting the epiglottis directly with the tip of the curved blade, thereby providing direct exposure to the larynx (see Figure 2). This is best accomplished with a standard geometry Macintosh blade, whether direct or video (eg, GlideScope Titanium Macintosh, McGrath Mac, or Storz C-Mac), as opposed to a hyperangulated video laryngoscope. Hyperangulated blades (standard GlideScope, Storz D blade, McGrath X-blade, and other hyperangulated devices such as King Vision) may not be long enough to reach down and elevate the epiglottis directly.