Engaging the hyoepiglottic ligament

Every Thursday morning at The Alfred ICU we spend an hour on practical teaching and training in airway and bronchoscopy skills. A common problem when novices perform laryngoscopy is failure to engage the hyoepiglottic ligament by properly seating the tip of the laryngoscope blade in the vallecula.

This can be hard to visualise… unless this you watch this video by the airway experts from the AIME course in Canada, as recently featured in EMCrit Podcast 142 – Airway Things I Learned from George Kovacs at the NYC Airway Course. This step is so important that George Kovacs even calls it “valleculoscopy”.

For a detailed description of the steps involved in direct laryngoscopy, see the LITFL CCC Direct Laryngoscopy page. Here is the description of epiglottoscopy and ‘valleculoscopy’, based on the Rich Levitan method:

• Move progressively down the tongue with the laryngoscope blade identifying relevant anatomy as you go and always find the epiglottis
• ‘epiglottoscopy’ is a prerequisite to exposure of the larynx, it is a gentle procedure
• initial blade insertion is with the laryngoscope handle pointed at the patient’s feet. The tongue and jaw are distracted downward to insert the blade
• once the tip of the blade gets around base of tongue the angle of distraction is altered so that the tongue is lifted, which transmits force via the hyoepiglottic ligament to lift the epiglottis edge is lifted off the posterior pharynx
• when the blade tip is seated in the vallecula the angle of lifting changes to ~40 degrees from the horizontal. Tip position (not force) is the main determinant of glottic exposure

To learn more about airway management in the critically ill, come along to The Alfred ICU’s Critically Ill Airway (CIA) course on 7 & 8 May 2015.