Let’s Change How We Talk About This Important Structure in Laryngoscopy
In airway speak, we often hear the phrase “seat in the vallecula” thrown around with the same casual ease as “find the epiglottis.” But let’s be clear: the vallecula is not just another landmark on the airway map—it’s a lever. And our job during laryngoscopy isn’t to find it, it’s to use it.
So let’s talk about how to communicate and teach this essential concept. Because what we do isn’t “valleculoscopy.” It’s valleculation — a purposeful maneuver that turns anatomy into action.
The Problem With the V in EVLI
Let me say first that I’m a big fan of teaching the progressive laryngoscopy approach to intubation. The step-by-step method of sequentially identifying key anatomic landmarks—popularized by George Kovacs as EVLI: Epiglottoscopy, Valleculoscopy, Laryngoscopy, and Intubation—is a powerful way to slow down, stay safe, and perform deliberate, high-quality endotracheal intubations.
But one little thing has always bothered me about the EVLI acronym. It’s the “V.”
Because the vallecula is not just another structure to identify. It’s unique—arguably the most important—because it’s the one space we are not simply observing, but actively engaging.
In fact, what we do isn’t valleculoscopy at all. It’s valleculation.
The vallecula is not a structure to merely identify. It’s a structure to occupy, act upon, manipulate, and leverage. Successful intubation often relies upon it because it’s the key to lifting the epiglottis and exposing the larynx. Reliable skills for acting in this vital space are, therefore, a critical and often overlooked component of laryngoscopy.
So let’s dive into the details of “valleculation” because I believe a more deliberate use of this new term can help us think (and teach) about the vallecula’s role in intubation more effectively.
Valleculation vs. Valleculoscopy
Why Language Matters
Let’s take a moment to look at the words themselves (I know the words are made up, but just go with it) because understanding the suffix we choose for our new vocabulary is more than just grammar. It shapes how we teach and perform the skill.
Latin Roots, Modern Meaning
In Practice:
Laryngoscopy and intubation are terms that are often used interchangeably in casual discussions, but they are different.
- Laryngoscopy is the act of visually exposing the larynx.
- Epiglottoscopy makes sense, too. We’re looking for it.
- Intubation is correct. It’s the act of inserting an endotracheal tube into the trachea.
- So what about the Vallecula?
If you call it “valleculoscopy,” you’re implying that your goal is to look at the vallecula—just observe it.
But that’s not what we do during laryngoscopy.
In short, -oscopy is passive. -ation is active.
And using the Vallecula requires action.
We valleculate—we engage the vallecula as a tool. We act upon it. We leverage the hyoepiglottic ligament to lift the epiglottis and expose the glottis.
Valleculation Defined
Let’s get the terminology straight:
Valleculation is the intentional engagement of the vallecula with a laryngoscope blade to transmit force through the hyoepiglottic ligament, elevating the epiglottis and exposing the glottic opening.
This is a biomechanical interaction—not a visual one. You are not looking for the vallecula. You are leveraging it.
When successful, valleculation lifts the epiglottis, clears the visual path, and improves the chance of a smooth intubation with minimal tissue trauma. For video laryngoscopy, valleculating also ensures that you are giving yourself enough room to deliver the tube in your field of vision.
Valleculation is Anatomy in Action
The vallecula is the mucosal space nestled between the glossoepiglottic folds, just anterior to the epiglottis. Embedded within this space lies the hyoepiglottic ligament, a connective tissue band tethering the epiglottis to the base of the tongue.
When you seat a laryngoscope blade in the vallecula, you’re not aiming for a better view of the vallecula itself—you’re using the blade to push forward and upward, transmitting force through the ligament to indirectly elevate the epiglottis.
This allows for:
- Improved glottic exposure
- Minimized trauma
- Efficient and safe tube delivery
Improve How We Address Performance Errors
This new terminology is helpful because we can be more concise when discussing common performance errors during validation and communicate to learners the active nature of micro-manipulation with the blade’s tip.
This is not about how you visualize the vallecula, it’s about how you actively engage it. Below are some common problems that can occur during the process of valleculation. To be effective at teaching how to correct them, we need to first signal that this is an active, not a passive process.
Teaching Valleculation: Practical Tips
This active terminology means that when we teach about engaging the vallecula, we are getting granular about the fine micro-skills and gestures with the blade tip that will optimize your view. Here are a few things we should be doing when teaching this aspect of laryngoscopy.
- Emphasize the Mechanism
Teach learners how the blade interacts with the hyoepiglottic ligament—not just where to place it. - Use the Right Language
Swap “find the vallecula” with “engage the vallecula.” This primes learners to think biomechanically. - Simulate the Feel
Encourage hands-on practice with task trainers that allow learners to feel the tension and release of proper valleculation. - Show Common Performance Errors
Not engaging midline, being too far back, or pushing too hard can all cause suboptimal engagement and lead to poor glottic visualization. - Illustrate the Ligament
Use visuals that show the ligament being stretched and the epiglottis rising—not just blade positioning.
The Bottom Line
The vallecula is not a structure to find—it’s a structure to use.
And once we shift our language and teaching toward valleculation, we empower clinicians with a clearer mental model and a more precise technique.
In airway management, words matter. So let’s stop saying valleculoscopy and start teaching the biomechanics that actually elevate success.
So the only question left to ask is
Do You Valleculate?
Visit This Learning Space
You can learn more about Valleculation and other key endotracheal intubation skills in our Join the OxygeNATION learning space. Part of the PAC universe of immersive, interactive, and hands-on training platforms.
For the Etymology Nerds (Like Me)
🔍 -oscopy
Origin: Latin -scopia, from Greek -skopia, from skopein — “to look at,” “to examine,” or “to observe.”
Meaning in English:
The suffix -oscopy refers to the act of viewing, observing, or examining—typically with a tool or scope. In medical contexts, it almost always implies a visual inspection of a body part using an instrument.
Examples:
- Laryngoscopy – the act of visually examining the larynx.
- Endoscopy – the use of an endoscope to visually inspect the inside of a body cavity.
- Colonoscopy – visual examination of the colon.
Key Concept:
-oscopy = visual examination. Passive observation is implied.
🔧 -ation
Origin: Latin -atio, -ationis, a suffix forming nouns of action from verbs.
Meaning in English:
The suffix -ation indicates the action or process of doing something. It turns a verb into a noun that describes an active process or result.
Examples:
- Intubation – the act of inserting a tube.
- Ventilation – the process of moving air in and out.
- Manipulation – the action of skillfully handling or controlling.
Key Concept:
-ation = an action or process. Active engagement is emphasized.
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