When indirect control of the epiglottis and laryngeal exposure proves difficult by the traditional Mac blade approach of placing the blade tip in the valleculae, consider repositioning the blade like in Miller blade technique to directly lift the epiglottis.

That is how you will deal with an epiglottic cyst or tumor should you encounter one. It may also be helpful should the epiglottis be swollen and immobile. In addition, lingual tonsillar hypertrophy will not allow the epiglottis to lift normally by indirect means. A particularly large and floppy epiglottis will also have difficulty with control by indirect lift (e.g. in pediatrics). Finally, if one cannot seat the blade properly in the valleculae due to limited mouth opening or large dentition restricted blade movement, then a direct lift of the epiglottis may work. Starting with the longer Mac 4 blade is helpful as it gives you these options without the need to switch your blade during your first attempt.

Be aware of the other responses to difficulty like external laryngeal manipulation when encountering poor laryngeal exposure and challenges in controlling the epiglottis.

Here is an example of where direct lift of the epiglottis allowed laryngeal inlet exposure for the intubation using indirect/video laryngoscopy.