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.