Videolaryngoscopy (McGrath/C-MAC) consistently provides better glottic views than direct laryngoscopy. Despite a Grade 1 Cormack-Lehane view on video, intubation fails. What is the most common reason for this paradox?

• A The ETT tip occluding the camera lens
• B Screen reflection causing misidentification of the glottis
• C Inability to direct the ETT to the visualised glottis due to the angulated blade requiring a highly curved stylet and loss of tactile feedback ✓
• D Laryngospasm triggered by videolaryngoscope insertion

Explanation

Hyperangulated videolaryngoscope blades (e.g., McGrath MAC, GlideScope) markedly improve visualisation but create an acute angle that makes directing the ETT into the glottis difficult without a pre-shaped (hockey stick) stylet. The tube must navigate around the blade's angle — a skill distinct from direct laryngoscopy technique. Soft tissue trauma and failed tube delivery despite excellent views are well-recognised with hyperangulated blades. Macintosh-geometry videolaryngoscopes (C-MAC) allow a hybrid technique where direct or indirect visualisation is used. Stylet angulation of approximately 60–90 degrees at the distal third is recommended.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.