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A large floppy epiglottis as a cause of difficult tracheal intubation

Asai, T.; Shingu, K.

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European Journal of Anaesthesiology: May 2001 - Volume 18 - Issue 5 - p 339-340


The laryngeal mask or intubating laryngeal mask can be useful in patients with difficult airways. A laryngeal mask may secure the airway if direct laryngoscopy, or even fibreoptic laryngoscopy, is difficult [1], but sometimes any procedure is difficult, especially with combinations of limited mouth opening, restricted head and neck movement, or oropharyngeal tumour [2,3]. We report that a large floppy epiglottis can make tracheal intubation difficult by conventional laryngoscopy, fibreoptic laryngoscopy, or via the laryngeal mask.

A 54-year-old female with quadriplegia and an ossified posterior longitudinal ligament of the neck was scheduled for laminectomy. Because of her unstable cervical spine and restricted neck movements, we thought that tracheal intubation would be difficult. The patient was sedated using fentanyl 50 µg and midazolam 3 mg; the oropharynx was sprayed with 8% lidocaine. A size 4 intubating laryngeal mask (Intavent, Reading, UK) was inserted with little discomfort to the patient and a 7.0-mm internal diameter reinforced tracheal tube (Mallinckrodt, Ireland) was then inserted over a fibrescope (Olympus, Japan) through the laryngeal mask.

We were unable to advance the fibrescope beyond the epiglottic elevating bar at the mask aperture, despite altering the position of the mask by its attached metal handle and replacing the size 4 by a size 3 mask. We then attempted conventional fibreoptic intubation, but the fibrescope would not advance beyond the epiglottis, which was large and floppy and up against the posterior pharyngeal wall (Figure 1). We encouraged the patient to breathe deeply, tried pulling the larynx forward by grasping the skin anteriorly, tried tilting the larynx by pressing on the lower larynx, and even tried direct laryngoscopy with a McCoy laryngoscope (Penlon, Abingdon, Berkshire, UK) but still were unsuccessful. All the time, the patient remained co-operative, propofol 100 mg in divided doses being given for sedation during laryngoscopy and fibrescopy.

Figure 1.
Figure 1.:
A large, floppy epiglottis was lying against the pharyngeal wall, making tracheal intubation by laryngoscope, fibrescope or via laryngeal mask difficult.

Eventually, 1 h after the start of the procedure and after about 40 min of attempts to advance the fibrescope beyond the epiglottis, we succeeded in placing a 6.0-mm reinforced tracheal tube in the trachea. Knowing about this difficulty of using the laryngeal mask should be a useful piece of information to anaesthetists dealing with the difficult airway.


1 Bapat P, Verghese C, Asai T, Brimacombe J. Unexpected difficult placement of laryngeal mask airways. Anaesthesia 1997; 52: 383–385.
2 Asai T, Hirose T, Shingu K. Failed tracheal intubation using a laryngoscope and intubating laryngeal mask. Can J Anaesth 2000; 47: 325–328.
3 Asai T. Difficulty in insertion of the laryngeal mask. In: Latto IP, Vaughan RS, eds. Difficulties in Tracheal Intubation, 2nd edn. Philadelphia: W.B. Saunders, 1997 :177–196.
© 2001 European Academy of Anaesthesiology