The McCoy laryngoscope expands the laryngeal aperture in patients with difficult intubation.

To the Editor:-The McCoy levering laryngoscope is a useful device,’.’ but does not uniformly improve the view in some cases of difficult laryngoscopy.’.’ We report a case in which the McCoy laryngoscope did not improve the direct view of the larynx, but instead lifted the epiglottis and expanded structures around the laryngeal aperture (LA), thereby facilitating “blind” tracheal intubation. A 72-yr-old woman (155 cm, 55 kg) with femoral neck fracture was scheduled to undergo surgical repair. At the preoperative visit, the patient’s airway could not be evaluated because she had senile dementia and could not respond to verbal commands. Anesthesia was induced with fentanyl 50 p g and thiopental 225 mg, and vecuronium 6 mg was administered. The patient’s lungs were easily ventilated through a face mask. At laryngoscopy with a Macintosh 3 blade (Welch Allyn, NY), only the epiglottis could be seen despite the application of optimal external laryngeal manipulation.* Three attempts at intubation with a stylet by blind probing failed. After several additional minutes of mask ventilation, an assistant nasally inserted a fiber-optic bronchoscope (FOB) (BF-P30; Olyrnpus, Tokyo) into the laryngopharynx to assess the area of the LA during laryngoscopy.5 With the FOR still in place, laryngoscopy using the Macintosh 3 blade was reattempted. Fiberscopy revealed that the epiglottis was close to the posterior pharyngeal wall, that the laryngoscope did not expand the structures around the LA, and that the LA area was very small. A McCoy levering kdryngoscope (Penlon, Abingdon, UK) was used to reattempt a fiber-optic assessment of the LA area. With the blade in the neutral position, the direct view and the fiber-optic view were similar to those obtained during Macintosh laryngoscopy (fig. IA). When the tip of the levered blade was elevated, only the slightly lifted epiglottis could be seen under direct vision; however, fiberscopy showed that the epiglottis was lifted, that the LA was markedly expanded, and that the glottis was clearly visible through the FOB (fig. lB). The FOB was removed and an endotracheal tube with the curved stylet was readiiy inserted into the trachea by blind probing with the levering laryngoscope blade in the elevated position. Successful placement of the endotracheal tube was confirmed by capnogaphy and aus cultation. Our case illustrates that even if the McCoy laryngoscope does not