Dear Editor,
A bifid epiglottis is defined as a cleft that extends at least two-thirds of the length of the epiglottis toward its base.[1] It is commonly associated with symptoms such as aspiration or stridor and is usually part of a syndromic presentation.[1,2,3,4,5] An isolated bifid anomaly has not been reported.[4] The most common syndromic association was found in Pallister–Hall syndrome, followed by in Bardet–Biedl syndrome.[1,2] Most of these cases involved life-threatening, severe inspiratory stridor and airway obstruction, with some requiring tracheostomy.[1] We report two cases of bifid epiglottis observed incidentally in adult and pediatrics on different occasions. Written and informed consent was taken for the publication of this case series.
In the first case, a 36-year-old male undergoing lumbar decompression and fixation had an uneventful perioperative course despite a bifid epiglottis noted on video laryngoscopy [Figure 1]. The anomaly was asymptomatic and discovered incidentally. In the second case, an 11-month-old non-syndromic male child weighing 8 kg, with a history of seizures since the age of 3 months, was scheduled for robotic stereotactic assistance-guided radiofrequency ablation for the hypothalamic hamartoma. The bifid epiglottis was not appreciated during elective intubation or might have been misinterpreted as the uvula or vocal cords [Figure 2a]. The intraoperative period was uneventful, and the child was extubated. On post-operative day (POD) 1, during emergency re-intubation for inspiratory stridor and hypoxia, the bifid epiglottis was misidentified as edematous vocal cords by a senior resident, leading to difficulty in intubation. Proper recognition on the second attempt by a faculty member led to successful intubation [Figure 2b]. The child was managed for stridor with adrenaline, levo-salbutamol, and budesonide nebulization along with dexamethasone 1.5 kg every 6 h for 3 days. On POD 5, the patient was successfully extubated and was discharged on POD 12 in stable condition with no neurological deficits.
Figure 1.
Bifid epiglottis as observed in adult male
Figure 2.
(a) Bifid epiglottis, mistaken for swollen vocal cords in an 11-month-old male child. (b) Bifid epiglottis, clearly visualized in an 11-month-old male child
Bifid epiglottis is typically associated with complex malformations, and almost all reported cases have presented with respiratory stridor.[1,2,3,4,5] However, our first adult patient was asymptomatic and did not report any complaints related to the anomaly. The epiglottic anomaly was purely incidental and did not pose any difficulty during intubation. In contrast, our second case was more consistent with previous reports, where the patient developed post-operative breathing difficulty and stridor. Most reported cases of bifid epiglottis have occurred in pediatric patients who are symptomatic. In our first case, the patient was asymptomatic, and the bifid epiglottis was recognized without complications. However, had the anesthesia team been unaware of this anomaly, it could have easily been misidentified, as seen in our second case, where the anesthesiologist had difficulty appreciating the vocal cords and sought assistance because it was missed during the previous elective intubation in the operation theatre. No previous case report or image has highlighted that a bifid epiglottis could resemble swollen vocal cords or a uvula. The aim of presenting these cases is to raise awareness among anesthesiologists, particularly those in training, about the possibility of such rare anomalies. Proper visualization of both the epiglottis and vocal cords is crucial to avoid difficulties during intubation in these types of situations.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
References
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