To the Editor: A patient with amyoplasia congenita (1) and previous unsuccessful endotracheal intubation with standard/McCoy laryngoscopy, intubating laryngeal mask, and fiberoptic bronchoscopy, was scheduled for scoliosis correction. Simplified airway risk index score (2) amounted to 10 (Table 1). Preoperative magnetic resonance imaging (MRI) revealed long, counterclockwise-rotated, and left-shifted epiglottis, clockwise-rotated hyoid, and short epiglottis tip-to-retropharyngeal wall distance (Fig. 1); anatomic abnormalities were probably explanatory of preceding intubation failure (Fig. 1, see legend). Following anesthesia-induction, a number 4 McCoy blade carrying a 7F Fogarty catheter (Fig. 2A) (3) was introduced through left mouth corner and above the left molars (4). Blade-tip was directed posteromedially (4), epiglottis was visualized, and blade-tip was advanced deep into vallecula. The handle was rotated clockwise so that its convex surface was parallel to line AT of Figure 1B. Fogarty catheter balloon inflation (Fig. 2B), forceful laryngoscope elevation, and external thyroid pressure resulted in exposure of posterior glottis commissure. A gum elastic bougie was introduced into the larynx, and a 6.5-mm-internal diameter endotracheal tube passed over it into the trachea. Conclusively, combined sagittal and transverse upper airway MRI sections may aid in difficult airway management planning. Anatomic abnormality-associated difficulties with epiglottis lifting may be attenuated with “left molar” McCoy-balloon laryngoscopy.Table 1: Preoperative Airway EvaluationFigure 1.: Preoperative magnetic resonance imaging sections of the upper airway. A, sagittal section 1 cm left to midline during “quiet” inspiration. The black dot represents the root of the epiglottis and the white dot represents its tip; epiglottis length amounts to 3.23 cm. The distance between epiglottis tip and retropharyngeal wall (R) is approximately 3 mm. H = hyoid bone; V = vallecula epiglottica; G = glottis. B, transverse section at the level of epiglottis tip (T). The epiglottis is shifted to the left and rotated counterclockwise; the angle between line AB and upper airway transverse axis (CD) is 25.1 degrees; line AB is tangential to the edges of the epiglottis laryngeal surface. The hyoid bone is rotated clockwise. C1 = right greater cornu of hyoid; C2 = left greater cornu of the hyoid. During the preceding, failed intubation attempts (see also main text), the abnormal epiglottis-hyoid anatomic relationship was the probable cause of ineffective epiglottis lifting with standard/McCoy laryngoscopy, whereas laryngeal mask insertion could have resulted in downward-folding of the elongated epiglottis; the elongated/left-shifted epiglottis probably resulted in inability of the endoscopist to advance a fiberscope around the epiglottis side and through the vocal cords. During the laryngoscopy reported herein, the McCoy-balloon blade was introduced into the vallecula epiglottica and then rotated clockwise so that its convex surface became approximately parallel to line AT; this maneuver along with the balloon-enhanced capability of upward hyoid/epiglottis lifting (see also Fig. 2B) should have been the major factors of the successful endotracheal intubation.Figure 2.: The modified number 4 McCoy-balloon laryngoscope blade used during the difficult airway management procedure reported herein. A 7F Fogarty catheter is attached on the concave surface of the blade. A, the laryngoscope blade was introduced into the left corner of the mouth with the McCoy lever pressed approximately halfway toward the laryngoscope handle, resulting in increase of blade tip angulation by 25–30 degrees. The tip of the Fogarty catheter is positioned behind the midpoint (white dot) of the cylindrical edge of the blade (Ε). B, modified blade configuration just after its “optimal” placement into the vallecula epiglottica (see also main text). The Fogarty catheter balloon is inflated with 2 mL of air.Spyros D. Mentzelopoulos, MD, PhD, DEAA Apostolos Armaganidis, MD, PhD Dimitra Niokou, MD Paraskevi Matsota, MD Maria Tzoufi, MD, DEAA Nikos Kelekis, MD, PhD Kostantinos Soultanis, MD, PhD Nikos Oikonomopoulos, MD Georgia Kostopanagiotou, MD, PhD Departments of *Intensive Care Medicine, †Anesthesiology, ‡Radiology, and §Orthopedic Surgery Attikon University Hospital Athens, Greece [email protected]