1.

Airway assessment
A physical examination of the airway should be preoperatively performed, when possible, to
detect any physical characteristics that may suggest a difficult airway. The specific
characteristics that should be evaluated in this examination are listed in Box 44.1.

 The visual inspection of the face and neck should focus on any physical
characteristics that may indicate the potential for difficulty with airway
management. These include obvious facial deformities, neoplasms involving the face
or neck, facial burns, a large goiter, a short or thick neck, or a receding mandible.
The presence of a beard has been shown to be associated with difficult ventilation
attributable to the difficulty in obtaining a mask seal. Cervical collars or cervical
traction devices can interfere with both mask ventilation and DL. A neck
circumference greater than 43 cm (17 inches) is associated with difficulty with
tracheal intubation34; Brodsky demonstrated that a large neck circumference is, in
fact, more predictive of difficulty with tracheal intubation than a high body mass
index (BMI).
 Assessment of mouth opening and inspection of the oropharyngeal anatomy is
achieved by instructing the patient to open his or her mouth as wide as possible. An
interincisor distance of less than 3 cm (or 2 fingerbreadths), as measured from the
upper to the lower incisors with maximal mouth opening, can suggest the possibility
of difficult intubation; some studies have used 4 or 4.5 cm as the cutoff. A thorough
inspection of the oropharynx can help identify pathologic characteristics that may
result in difficulty with intubation, such as neoplasm, a high arched palate, or
macroglossia. Mallampati and associates described a clinical sign to predict difficult
tracheal intubation based on the size of the base of the tongue. A Mallampati
classification of I to III is assigned, based on the visibility of the faucial pillars, uvula,
and soft palate when the patient is seated upright with the head neutral, the mouth
open, the tongue protruded, and no phonation. Higher scores on the Mallampati
classification indicate poor visibility of the oropharyngeal structures attributable to a
large tongue relative to the size of the oropharyngeal space, and, subsequently, a
more difficult laryngoscopy. The modified Mallampati classification described by
Samsoon and Young, which adds a fourth classification, is the most commonly used
airway assessment test in current anesthesia practice and is defined as follows (Fig.
44.8):
  Class I : Faucial pillars, uvula, and soft palate are visualized.
 Class II : Base of the uvula and soft palate are visualized.
 Class III : Soft palate only is visualized.
 Class IV : Hard palate only is visualized.
 An examination of dentition should be performed when the oropharyngeal anatomy
is being evaluated. Relatively long upper incisors can impair DL. Poor dentition and
loose teeth increase the risk of dental trauma and present a risk of tooth
dislodgment with subsequent aspiration; very loose teeth should be removed before
laryngoscopy. Cosmetic dental work, such as veneers, caps, crowns, and bridges, are
particularly susceptible to damage during airway management. Edentulousness is
predictive of easy tracheal intubation but potentially difficult mask ventilation.
 The ideal positioning for DL is achieved by cervical flexion and atlantooccipital
extension and is most commonly referred to as the sniffing position (see Direct
Laryngoscopy: Preparation and Positioning). Assessment of a patient’s ability to
assume this position should be included in the airway examination; an inability to
extend the neck at the atlantooccipital joint is associated with difficult intubation.
Head and neck mobility can also be quantitatively assessed by measuring the
sternomental distance between the sternal notch and the point of the chin with the
head in full extension and the mouth closed. Distances less than 12.5 cm are
associated with difficult intubation. An assessment of overall neck range of motion
can be performed by measuring the angle created by the forehead when the neck is
fully flexed and then fully extended; a measurement of less than 80 degrees is
predictive of difficult intubation.
 During DL, the tongue is displaced into the submandibular space; glottic visualization
may be inadequate if this space is diminished because of a small mandible. This
scenario is frequently referred to as an anterior larynx. A thyromental distance of
less than 6.5 cm (3 fingerbreadths), as measured from the thyroid notch to the lower
border of the mentum, is indicative of reduced mandibular space and may predict
difficulty with intubation. Compliance of this space should also be assessed; a lack of
compliance or the presence of a mass is a nonreassuring finding.
  Tests of the ability for mandibular protrusion (prognathism) have predictive value
and should be included in the airway assessment. The inability to extend the lower
incisors beyond the upper incisors may be indicative of difficult laryngoscopy. A
similar evaluation, the upper lip bite test (ULBT) described by Khan and colleagues,
has been shown to predict difficult laryngoscopy with higher specificity and less
interobserver variability than the Mallampati classification; an inability of the lower
incisors to bite the upper lip is associated with more difficult laryngoscopy

Mallampati, range of motion