What is the treatment for a curled up epiglottis?

Treatment for Curled Up Epiglottis

The primary treatment for a curled up (downfolded) epiglottis is insertion of a laryngeal mask airway (LMA) behind the tracheal tube, which splints the epiglottis and prevents downfolding while maintaining airway patency during extubation. 1

Diagnosis and Assessment

Before treatment, proper diagnosis is essential:

• Direct visualization via flexible laryngoscopy is the gold standard for diagnosis of epiglottic abnormalities 2
• Perform examination in a controlled setting with emergency airway equipment readily available, as examination may precipitate airway obstruction 2
• A routine oropharyngeal examination may appear normal in up to 44% of cases of epiglottic disorders 3

Treatment Options Based on Clinical Scenario

1. During Extubation (Anesthesia Setting)

When a curled up epiglottis is identified during extubation:

• LMA Exchange Technique (Bailey maneuver) 1:
  1. Administer 100% oxygen
  2. Avoid airway stimulation using deep anesthesia or neuromuscular blockade
  3. Perform laryngoscopy and suction under direct vision
  4. Insert deflated LMA behind the tracheal tube
  5. Ensure LMA placement with tip in correct position
  6. Inflate LMA cuff
  7. Deflate tracheal tube cuff and remove tube while maintaining positive pressure
  8. Continue oxygen delivery via LMA
  9. Insert bite block
  10. Position patient upright
  11. Allow undisturbed emergence from anesthesia

This technique is superior to either awake or deep extubation for patients with epiglottic issues, as it maintains a patent, unstimulated airway with stable physiological observations 1.

2. For Acute Epiglottitis with Curled Epiglottis

For infectious or inflammatory causes:

• Immediate airway management is the priority 4, 5
• All patients should be admitted to intensive care for close monitoring 4
• Medical management includes:
  • Antibiotics (appropriate for suspected pathogens)
  • NSAIDs for inflammation reduction
  • Possibly adrenaline inhalation to reduce swelling 3
  • Corticosteroids at least 6 hours before extubation if there is concern for laryngeal edema 2

3. For Foreign Body Causing Epiglottic Displacement

If a foreign body is causing epiglottic displacement:

• Follow choking management protocol 1:
  • Back blows (five smart blows to middle of back)
  • Chest thrusts (five thrusts to sternum)
  • Check mouth and remove visible foreign bodies
  • Open airway using head tilt and chin lift or jaw thrust
  • Attempt rescue breathing if needed

Special Considerations

• Preparation for difficult airway management is crucial, with emergency airway equipment ready and a tracheotomy set at bedside 2
• In severe cases where other methods fail, surgical intervention may be necessary 6
• For children with nasal or airway hemangiomas affecting the epiglottis, propranolol therapy may be considered 1

Monitoring After Treatment

• Close observation for at least 24 hours after intervention is recommended for signs of respiratory distress 2
• Reintubation equipment should be readily available for at least 24 hours post-extubation 2
• Continuous or regular oxygen saturation monitoring is recommended to ensure adequate oxygenation 2

Pitfalls to Avoid

• Never perform blind finger sweeps of the pharynx as these can impact a foreign body in the larynx 1
• Do not attempt conventional oral endotracheal intubation without having emergency equipment available, as failed intubation can be fatal 3
• Do not delay securing the airway to obtain radiographs if there are signs of impending airway obstruction 4
• Recognize that stridor is an important acute sign of upper airway obstruction requiring immediate intervention 7

The LMA exchange technique is particularly valuable as it splints the epiglottis in the correct position during removal of the endotracheal tube, preventing the epiglottis from curling or downfolding and causing airway obstruction during emergence from anesthesia.