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. Although not necessarily pathological, it may be associated with laryngomalacia and supraglottitis. 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. 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.