Displacement of the epiglottis, also known as epiglottic folding, downfolding, or prolapse, is an unexpected complication associated with tracheal intubation and supraglottic airway device insertion. Recent advancements in endoscopic technology and the widespread use of video/optical devices, such as videolaryngoscopes, have brought this phenomenon to light. If this complication is overlooked, the epiglottis may become ischemic and edematous, potentially inducing airway obstruction during the perioperative period.

In our practice, videolaryngoscopes are the first choice for tracheal intubation. We also use them to verify the proper placement of the tracheal tube, particularly in procedures performed by residents. Additionally, videolaryngoscopes are employed for nasogastric tube placement and transesophageal echocardiography probe insertion.

Through this observation, we have categorized epiglottal displacement into four distinct types. As shown in figure 1, grade 0 represents the normal condition. Grade 1 is characterized by lateral displacement, which may occur in either direction. Grade 2 indicates partial folding; a portion of the epiglottis is visible (white arrowhead). Grade 3 denotes complete folding. The images were obtained from AceScope (AceMedical, Korea) internal storage. The supplemental video (Supplemental Digital Content, https://links.lww.com/ALN/D467) shows a grade 3 case, with complete folding of the epiglottis caused by intubation procedure performed by novice resident.

Fig. 1.
Classification of epiglottal displacement. Grade 0: normal epiglottis position. Grade 1: epiglottis (white arrowhead) is displaced laterally. Grade 2: partial folding; part of epiglottis can be seen (white arrowhead). Grade 3: complete folding; no epiglottis can be seen as it is folded into the trachea along with the tube. Images were obtained from AceScope (AceMedical, Korea) internal storage.

Classification of epiglottal displacement. Grade 0: normal epiglottis position. Grade 1: epiglottis (white arrowhead) is displaced laterally. Grade 2: partial folding; part of epiglottis can be seen (white arrowhead). Grade 3: complete folding; no epiglottis can be seen as it is folded into the trachea along with the tube. Images were obtained from AceScope (AceMedical, Korea) internal storage.

Compared to conventional direct Macintosh laryngoscopes, videolaryngoscopes require less lifting force for laryngeal exposure. Therefore, in cases of poor laryngeal visibility, alternative approaches, such as those resembling the Miller blade technique, which scoops the epiglottis from behind, are acceptable. However, these approaches may not always permit visual confirmation of the epiglottis’s position even through the translucent blade, potentially leading to unexpected folding.  Insertion of the tube in such conditions may impede the spontaneous repositioning of the epiglottis, as the tube acts as a wedge door stopper, preventing its movement. Close monitoring of the epiglottis condition during the intubation procedure is important, and operators should ensure that the epiglottis is not folded when removing the laryngoscope to enhance patient safety. In this context, videolaryngoscopes equipped with a recording function offer significant advantages. Avoiding epiglottis folding is critical, as it can occur without notice, and preventing its occurrence may minimize epiglottic injuries associated with tracheal intubation.