Anaesthesia, 1998, 53, pages 1041–1044

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Evaluation of an improved scoring system for the grading

of direct laryngoscopy

S. M. Yentis1 and D. J. H. Lee2

1 Consultant Anaesthetist, Magill Department of Anaesthetics, Chelsea & Westminster Hospital, 369 Fulham Road,
London SW10 9NH, UK
2 Senior Registrar, Department of Anaesthetics, King’s College Hospital, Denmark Hill, London SE5 9RS, UK

Summary
A modified version of the Cormack and Lehane scoring system was prospectively evaluated in 663
patients requiring tracheal intubation. In the modified system, grade 2 (only part of the glottis
visible) was divided into 2a (part of the cords visible) and 2b (only the arytenoids or the very
posterior origin of the cords visible). One hundred and sixty-two intubations (24.4%) were scored
as grade 2a and 43 (6.5%) as grade 2b, of which seven (4.3%) and 29 (67.4%), respectively, were
difficult, defined as requiring more than one laryngoscopy or the use of specialist equipment.
Grade 2b denotes a laryngoscopic view that is relatively common and is often associated with
difficulty passing a tracheal tube. The modified scoring system thus provides more information
than the original Cormack and Lehane system and its use should be considered when recording
the ease of tracheal intubation in the anaesthetic record or in studies of tracheal intubation.

Keywords Intubation; tracheal.

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Correspondence to: Dr S. M. Yentis
Accepted: 1 May 1998

The four-grade scoring system described by Cormack and (any part of the inlet visible) being recorded in the patient’s
Lehane in 1984 [1] is widely used in clinical practice to notes even though considerable difficulty may have been
describe the view obtained at direct laryngoscopy, both for encountered at intubation. There is thus a need for a more
clinical studies and to aid anaesthetists involved in the sensitive scoring system. Others have proposed five or
subsequent management of patients in whom difficulty more grades with various modifications [3–5] but there
occurred. However, the Cormack and Lehane system was have so far been no evaluations of how useful the extra
described as a means of simulating difficult tracheal intu- information might be, especially in patients in whom
bation in order to teach trainees in obstetric general tracheal intubation has been awkward or difficult.
anaesthesia, not as a grading system for everyday recording The aims of this study were to apply a previously
of the view at laryngoscopy [1]. In addition, Cohen et al. described modified scoring system based on the Cormack
found that few anaesthetists realised that the original and Lehane system [6], ascertain the incidence of the
Cormack and Lehane system referred to the best view different grades in a population of general anaesthetic
obtained, i.e. with or without manipulation of the larynx. patients and, in cases where tracheal intubation was
They also found that there was considerable confusion as difficult, compare the information obtained with that
to what constituted the different grades [2]. noted during previous anaesthetics.
One problem with the Cormack and Lehane system is
that the more difficult laryngoscopies, scoring grades 3
Methods
(epiglottis only) or 4 (no laryngeal structure visible), are
relatively uncommon in clinical practice, whereas an Successive patients aged 16 years and over requiring
anaesthetist is more likely to experience difficulty in tracheal intubation for elective surgery, but excluding
tracheal intubation despite part of the laryngeal inlet those in whom rapid sequence induction of anaesthesia
being visible. This would lead to a grade 2 laryngoscopy was indicated, were studied. After discussion with the

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S. M. Yentis and D. J. H. Lee • Grading of direct laryngoscopy Anaesthesia, 1998, 53, pages 1041–1044
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Figure 1 Description of the two scoring systems used. E ¼ epiglottis, LI ¼ laryngeal inlet.

Ethics Committee Chairman, specific consent was not

Results
obtained from the patients since no extra intervention or
procedure was involved. All patients were anaesthetised Six hundred and sixty-three patients were studied. There
using standard agents and paralysed using nondepolarising were 163 males and 500 females, reflecting the largely
neuromuscular blocking drugs, sufficient time being gynaecological clinical workload of one of the authors.
allowed for relaxation to be achieved before laryngoscopy Mean (SD) [range] age and weight of the patients were
was attempted, according to the recommended intervals in 49.2 (18.2) [16–97] years and 70.3 (16.4) [35–150] kg,
the manufacturers’ data sheet and the published literature. respectively. Three hundred and seventy-six laryngo-
All laryngoscopies and intubations were performed by the scopies were performed by S.M.Y. and 287 by D.L.
authors, both anaesthetists of several years’ experience, There were no failed intubations. The distribution of
who attempted to obtain the clearest view at laryngoscopy, the grades of laryngoscopies is shown in Fig. 2.
including the use of cricoid pressure or other manipula- Forty-seven intubations were described as ‘difficult’ as
tions of the larynx [7], before intubating the trachea. defined above. The distributions of these cases within each
Each laryngoscopy was graded using the standard laryngoscopic grade and for each grading system are
Cormack and Lehane scoring system [1] and the modified shown in Table 1. Of the ‘difficult’ cases, 19 required
system [6], which was in turn modified from that more than one laryngoscopy, 31 required the use of a gum
described by Wilson et al [3]. The two systems used are elastic bougie, nine required a long laryngoscope blade and
shown in Fig. 1. The modified system was further four required a different design of laryngoscope blade (a
categorised by the suffix ‘D’ to denote difficulty with Bellhouse blade was used in one case, a straight blade in
tracheal intubation. This was defined for the purpose of another and a McCoy blade in the two other cases). In
this study as requiring more than one laryngscopy, a 34 cases, no previous record of laryngoscopy was available;
specialist blade or other intubation aid such as a gum in seven, ‘grade 2’ was noted with no mention of diffi-
elastic bougie. culty; in six, some indication of difficulty was noted.

Table 1 Distributions of difficult tracheal

Cormack & Total Number (%) Modified Total Number (%) intubation for the two scoring systems.
Lehane grade [1] number difficult grade number difficult

1 450 4 (0.9) 1 450 4 (0.9)

2 205 36 (17.6) 2a 162 7 (4.3)
2b 43 29 (67.4)
3 8 7 (87.5) 3 8 7 (87.5)
4 0 4 0

Total 663 47 663 47

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Anaesthesia, 1998, 53, pages 1041–1044 S. M. Yentis and D. J. H. Lee • Grading of direct laryngoscopy
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complexity of the intubation difficulty scale will preclude

its acceptance as a scoring system to be routinely recorded
by anaesthetists. In addition, it relies on the original
Cormack and Lehane system, the insensitivity of which
is the subject of this paper.
The system described is not the only or first modifica-
tion of the Cormack and Lehane system to be suggested
[3–5]. Wilson et al. used a five-point scale in their investi-
gation of difficult intubation and its prediction. They
defined grade 2 as ‘only half the cords visible’ and grade
3 as ‘only the arytenoids visible’, with grades 4 and 5
being the same as Cormack and Lehane’s grades 3 and 4,
respectively [3]. The version we used has the advantage of
avoiding the requirement for estimating the proportion of
the cords that is unseen. In addition, if only the posterior
origin of the cords is visible, there may be as much
Figure 2 Distribution of the grades of laryngoscopies using the difficulty as if only the arytenoids are visible. Wilson et
modified scoring system. The original Cormack and Lehane al. found that in 12% of intubations (allowing for external
system [1] would group grades 2a and 2b into one grade (grade laryngeal pressure), half of the cords or less was visible but
2), having an incidence of 30.9% of laryngoscopies. they did not provide information on how much of the
cords were seen in this group, or how often difficulty was
encountered [3]. It has been suggested by others [4, 5] that
the Cormack and Lehane system should be subdivided
Discussion
further into 3a and 3b (denoting, respectively, only epi-
A sizeable proportion of patients are ill-served if the glottis visible and only epiglottis visible but adherent to the
original Cormack and Lehane grading system is used as posterior pharyngeal wall). However, grade 3 as a whole is
a means of recording ease of laryngoscopy and intubation, uncommon, as we and others [3] have shown, and the
even if its application were to be consistent amongst more subdivisions there are, the more confusing the
anaesthetists [2]. We feel that the extra information con- system becomes. For example, one could suggest further
ferred by the improved scoring system for those 6.5% of subdivisions ad infinitum, e.g. 3c for tenacious sputum and
patients who would otherwise have been graded Cormack 3d for an abnormally shaped epiglottis. Any scoring system
and Lehane grade 2 will prove to be useful to subsequent must therefore be a compromise between its ability to deal
anaesthetists, as demonstrated by the high incidence (67%) with common occurrences, its comprehensiveness and its
of difficulty associated with grade 2b laryngoscopies. simplicity. Ideally, we would have liked to have reclassified
Indeed, we found that had this system been in place, we the system altogether into a five point scale as did Wilson et
would have been better informed on seven occasions in al. [3], but this would lead to uncertainty as to which
which intubation was awkward for us, assuming similar system, for example, a grade 3 referred. We therefore
laryngoscopic views were obtained previously. Whilst no adhered to the familiar Cormack and Lehane four point
patient came to any harm as a result of this, it is easy to scale. Finally, it has been suggested that the scoring system
envisage a situation where an inappropriate anaesthetist is should include the suffix ‘þ’ for easy manual ventilation of
allocated or an inappropriate technique is employed to the lungs by facemask and ‘¹’ for impossible manual
deal with a patient who has posed problems previously, but ventilation [5]. We feel that this information should be
this fact has gone unrecorded. Ultimately, one is depen- written separately and its addition would only serve to add
dent on the previous anaesthetist’s diligence in recording to the complexity of the scoring system, which should be
details of any case and there is a compromise between reserved primarily for scoring the laryngoscopy. To this
demanding the maximum amount of information recorded end, we have added our own suffix ‘D’ to indicate
and the chances of actually obtaining it. Adnet et al. have difficulty with intubation (as defined above) for the
recently described an intubation difficulty scale which purpose of presenting our data, although we accept that
includes measures of the number of attempts at intubation, it would be better to record the reason for difficulty rather
number of operators, number of alternative techniques, than merely add the suffix when recording the clinical
Cormack and Lehane grade, lifting force required, laryn- course of airway management in the patients’ notes. Some
geal pressure and vocal cord mobility [8]. However, whilst measure of difficulty that does not depend exclusively on
this may be useful in studies of intubation, we feel that the the best laryngoscopic view alone has particular value in

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certain circumstances, for example the grade 1 view where described above when investigating laryngoscopic views,
intubation is hindered by a prominent but unfortunately especially when comparing groups.
placed tooth, or the grade 1 view that is obtained only after
the use of a specialist blade. References
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