Omega-shaped epiglottis: a challenge

A heavy smoker 49-year-old man, American Society of Anestesiologists (ASA) physical status III, with positive history of gradually worsening dyspnea was proposed for Suspension Microlaryngoscopy surgery. Airway evaluation showed a grade-III Mallampati score and no apparent or palpable cervical mass. After preoxygenation and induction, orotracheal intubation was performed with C-MAC D blade Videolaryngoscope®, and founded an omega-shaped epiglottis (OSE) (Fig. 1), with vocal cords visualized only after lifting the epiglottis with the tip of the curved blade (Fig. 2). Intubation was accomplished using a 4.0- mm cuffed microlaryngeal orotracheal tube, anesthesia was maintained with sevoflurane and controlled ventilation. Anesthesia emergency was uneventful.

Figure 1
Omega-shaped epiglottis visualized with C-MAC D Blade videolaryngoscope.

Figure 2
Exposition of larynx and vocal cords after lifting epiglottis.

OSE is a variant configuration of epiglottis in which the lateral folds are curled inwards.¹ Although not necessarily pathological, it may be associated with laryngomalacia and supraglottitis.² From the anesthetic point of view, potential problems of OSE include variable airway obstruction and compromise. Anatomical changes of the epiglottis should serve as a warning for difficult airway, namely with facemask ventilation and orotracheal intubation/extubation.³ Preoperative anesthetic evaluation should include investigation symptoms suggestive of intermittent airway obstruction and image evaluation (MRI or CT-scan of the head and neck) (Fig. 3).

Figure 3
CT-Scan of head and neck showing omega epiglottis.

References

• ¹
  Ayari S, Aubertin G, Girschig H, et al. Pathophysiology and diagnostic approach to laryngomalacia in infants. Eur Ann Otorhinolaryngol Head Neck Dis. 2012;129:257-63.
• ²
  Kovacs A, Haran S, Paddle P. Chronic non-granulomatous supraglottitis of a male adolescent and its successful management with azathioprine. BMJ Case Reports CP. 2019;12:e227458.
• ³
  Laschat M, Kaufmann J, Wappler F. Laryngomalacia with Epiglottic Prolapse Obscuring the Laryngeal Inlet. Anesthesiology. 2016;125:398.

Publication Dates

• Publication in this collection
  30 July 2021
• Date of issue
  Jul-Aug 2021

History

• Received
  18 Dec 2020
• Accepted
  27 Feb 2021
• Published
  21 Mar 2021