Velo-epiglottic Adhesion: An Unusual Finding in a Mallampati Zero Airway

The figure is from the preanesthetic airway assessment of a 56-yr-old man scheduled for laparoscopic hernia repair. His epiglottis was visible on tongue protrusion (unusual “Mallampati Zero” classification) and was adhered to the uvula as well. The patient related an uneventful past surgical history, although airway management for previous procedures was unknown, as they occurred at an outside facility. He also reported no difficulties in breathing, swallowing, or vocalizing. Endotracheal intubation for his surgery was straightforward; there was easy glottic visualization via standard direct laryngoscopy with a Mac 3 blade. No adhesion or other anatomical abnormality was noted in the operator’s field of view.

Velo-epiglottic adhesion is sparsely represented in the literature and may result from trauma, radiation therapy, surgical scarring, or congenital anomaly.  Clinical signs and symptoms, when present, include dysphagia, shortness of breath or stridor, and dysphonia. The condition complicates airway management by limiting epiglottic movement on laryngoscopy (video or direct), potentially leading to difficult intubation.  In addition, if pharyngeal adhesion(s) are sufficiently large or restrictive, it may be impossible to place a supraglottic airway. Ideally, patients should have adhesions surgically corrected before undergoing elective procedures. If this is not possible, alternative airway management strategies such as fiberoptic intubation may be required. Obvious anatomic abnormalities may or may not correlate with difficult airway management, a statement that also holds true for Mallampati Zero airways in general.  Regardless, patients having symptoms arising from adhesion, or adhesion-related difficulties in airway management, should seek otolaryngology consultation postprocedure(s).