The use of DryShield versus rubber dam isolation systems among pediatric patients with different airway patency: A randomized clinical trial.

Objectives: This randomized clinical trial aimed to evaluate the impact of DryShield isolation (DSI) and rubber dam isolation (RDI) system usage on vital signs, behavior, pain and discomfort, and chairside time required among children with different airway patencies based on the Modified Mallampati Classification (MMC). Material and methods: Healthy, cooperative children who required fissure sealant in at least two contralateral, fully erupted, permanent first molars were included. Airway patency was determined by two trained and calibrated dentists using the MMC. The participants were categorized based on their MMC scores into patent airways (classes I and II) and non-patent airways (classes III and IV). The dental procedure was videotaped during treatment, and vital signs, including arterial oxygen saturation, heart rate, and blood pressure, were recorded every 3 min. The participants' subjective pain and discomfort were evaluated using a previously validated Arabic interview questionnaire and a validated Arabic version of the Wong-Baker Faces Pain Rating Scale. The participants' behavior and behavioral pain were evaluated utilizing the Frankl Behavior Scale and the face, legs, activity, cry, and consolability scales, respectively. Results: There were no significant differences in any of the vital signs between DSI and RDI. DSI use yielded a significant reduction in chairside time (P < 0.001) and was more bothersome (P < 0.001) than RDI use among all participants, regardless of airway patency. DSI was associated with significantly better behavior during the dental procedure (P = 0.002) and less behavioral pain (P < 0.001) among all participants, regardless of airway patency. Conclusion: Irrespective of airway patency, DSI outperformed RDI in terms of behavior, pain, and procedure duration; however, DSI was characterized by noise, pressure on soft tissues, and an increased tendency to induce gag reflexes.

Prediction of difficult laryngoscopy and/or intubation among morbidly obese patients: Upper lip bite test versus modified Mallampati classification.

INTRODUCTION: We aim to compare the upper lip bite test with the modified Mallampati test as predictors of difficult laryngoscopy and/or difficult intubation among morbidly obese patients. METHODS: A total of 500 morbidly obese patients (body mass index > 40 kg/m2) undergoing general anaesthesia with tracheal intubation are included in this prospective single-blinded observational clinical study. The preoperative airway assessment is obtained by the modified Mallampati test and upper lip bite test. The difficulty of laryngoscopy is assessed by an experienced anaesthetist in patients adequately anaesthetised and fully relaxed. The view is classified according to Cormack and Lehane's classification. Modified Mallampati test III or IV and upper lip bite test III are considered positive tests. Difficult laryngoscopy is defined as Cormack and Lehane's classification III and IV, whereas difficult endotracheal intubation is defined as an intubation difficulty scale ⩾ 5. RESULTS: The incidences of Cormack and Lehane's classification III and IV and intubation difficulty scale ⩾ 5 are 9.4% and 11.8% respectively. The specificity, positive predictive value and accuracy are higher with the upper lip bite test. The combination of the upper lip bite test and the modified Mallampati test improved these measures. The likelihood ratio + was significantly higher for the upper lip bite test (6.35 and 9.47) than for the modified Mallampati test (3.21 and 3.16). CONCLUSION: The upper lip bite test is a test with high sensitivity, specificity, negative predictive value and accuracy making it a favourable test for identifying easy and difficult intubations and laryngoscopies in morbidly obese patients.

Evaluation of changes in Mallampati class in patients undergoing lumbar spine surgeries in the prone position: A prospective observational study.

Background: Positioning of patients during surgery, whether prone or head down, can lead to airway edema which, in turn, may lead to a difficult airway, and enhanced chances for reintubation. We aimed to assess and evaluate modified Mallampati class (MMC) change in patients scheduled for lumbar spine surgery in the prone position. Materials and Methods: This prospective observational study included 80 patients scheduled for lumbar spine surgery. The MMC was assessed up to 48 h postoperatively. The time taken by the patients in the postoperative period for MMC class to revert to preoperative value and airway complications, if any, was noted. Other parameters observed were surgical duration, intraoperative fluids used, and blood loss to look for any significant correlation with changes in MMC. Results: MMC increase by one grade was observed in 73 patients (91%). MMC in 54 patients (74%) returned to baseline within 18 h, in 12 patients (16%) it took 24 h, and in the remaining 7 patients (10%) the time taken was 36 h. Conclusion: It was concluded and established by this study that the MMC declined by one grade and reverted to baseline value within 36 h. This change in MMC necessitates extra caution to be adopted during the postoperative period as surgery in a prone position may predispose to an increased risk of encountering difficult reintubation. The change in MMC was not significantly correlated to intraoperative variables like duration of surgery, amount of intraoperative fluid given, and blood loss.

Predictive value of NoSAS questionnaire combined with the modified Mallampati grade for hypoxemia during routine sedation for gastrointestinal endoscopy.

BACKGROUND: The incidence of hypoxemia during painless gastrointestinal endoscopy remains a matter of concem. To date, there is no recognized simple method to predict hypoxemia in digestive endoscopic anesthesia. The NoSAS (neck circumference, obesity, snoring, age, sex) questionnaire, an objective and simple assessment scale used to assess obstructive sleep apnea (OSA), combined with the modified Mallampati grade (MMP), may have certain screening value. This combination may allow anesthesiologists to anticipate, manage, and consequently decrease the occurrence of hypoxemia. METHODS: This study was a prospective observational trial. The primary endpoint was the incidence of hypoxaemia defined as pulse oxygen saturation (SpO2) < 95% for 10 s. A total of 2207 patients admitted to our hospital for painless gastrointestinal endoscopy were studied. All patients were measured for age, height, weight, body mass index, neck circumference, snoring, MMP, and other parameters. Patients were divided into hypoxemic and non-hypoxemic groups based on the SpO2. The ROC curve was plotted to evaluate the screening value of the NoSAS questionnaire separately and combined with MMP for hypoxemia. The total NoSAS score was evaluated at cut-off points of 8 and 9. RESULTS: With a NoSAS score ≥ 8 as the critical value for analysis, the sensitivity for hypoxemia was 58.3%, the specificity was 88.4%, and the area under the ROC was 0.734 (P < 0.001, 95% CI: 0.708-0.759). With a NoSAS score ≥ 9 as a critical value, the sensitivity for hypoxemia was 36.50%, the specificity rose to 96.16%, and the area under the ROC was 0.663 (P < 0.001, 95% CI: 0.639-0.688). With the NoSAS Score combined with MMP for analysis, the sensitivity was 78.4%, the specificity was 84%, and the area under the ROC was 0.859 (P < 0.001, 95%CI:0.834-0.883). CONCLUSIONS: As a new screening tool, the NoSAS questionnaire is simple, convenient, and useful for screening hypoxemia. This questionnaire, when paired withMMP, is likely to be helpful for the screening of hypoxemia.

Upper lip bite test compared to modified Mallampati test in predicting difficult airway in obstetrics: A prospective observational study.

Difficult airway and intubation can have dangerous sequela for patients if not managed promptly. This issue is even more challenging among obstetric patients. Several studies have aimed to determine whether the test to predict a difficult airway or difficult intubation, is higher in accuracy. This study aims to compare the upper lip bite test with the modified Mallampati test in predicting difficult airway among obstetric patients. During this prospective observational study, 184 adult pregnant women, with ASA physical status of II, were enrolled. Difficult intubations of Cormack-Lehane grade III and IV were defined as difficult airways and difficult intubation in this study. Upper lip bite test, modified Mallampati test, thyromental distance and sternomental distance were noted for all patients. Modified Mallampati test, upper lip bite test and sternomental distance had highest specificity. Based on regression analysis, body mass index and Cormack-Lehane grade have a significant association. Modified Mallampati test was the most accurate test for predicting difficult airway. The best cut-off points of thyromental distance and sternomental distance in our study were 5cm and 15cm, respectively, by receiver operating characteristic curve analysis. Based on the results of the present study, it can be concluded that in the obstetric population, modified Mallampati test is practically the best test for predicting difficult airway. However, combining this test with upper lip bite test, thyromental distance and sternomental distance might result in better diagnostic accuracy.

Predictive values of the modified Mallampati test, upper lip bite test, thyromental distance and ratio of height to thyromental distance to predict difficult laryngoscopy in pediatric elective surgical patients 5-12 years old at selected Addis Ababa governmental hospitals, Ethiopia: a multicenter cross-sectional study.

BACKGROUND: Maintaining patent airways is vital in pediatric anesthetic management. Failure to manage and anticipate difficult laryngoscopy (DL) preoperatively is the leading cause of morbidity and mortality. Data on the predictive values of screening parameters in predicting DL are limited in children. Therefore, this study aimed to assess the predictive value of the modified Mallampati test (MMT), upper lip bite test (ULBT), thyromental distance (TMD), and ratio of height to thyromental distance (RHTMD) in predicting DL in children aged 5-12 years at selected Addis Ababa governmental hospitals in Ethiopia. METHODS: A multicenter cross-sectional study was conducted on 141 elective pediatric surgical patients aged 5 to 12 years selected using a systematic random sampling technique at three governmental hospitals from December 1, 2021, to April 30, 2022. The collected data were entered and analysed by SPSS version 26. Chi-square and Fisher's exact tests were used to compare categorical variables. The receiver operating characteristic curve analysis was used to compare the accuracy of MMT, ULBT, TMD, and RHTMD against DL. A P value < 0.05 was considered statistically significant. RESULTS: The magnitude of DL was 15.6%. MMT has the highest sensitivity (86.4%), specificity (91.6%), and negative predictive value (NPV) (97.3%) compared to other tests. The ULBT also has a high sensitivity (72.7%) and specificity (84%) with comparable diagnostic accuracy (90.8%) with the MMT (P < 0.05). The sensitivity, specificity, positive predictive value (PPV), NPV, and accuracy of TMD were 63.6%, 95.8%, 73.7%, 93.4%, and 82.2%, respectively. The RHTMD has the lowest specificity (63.6%), PPV (22.5%), NPV (91.4%), and accuracy (56.7%) in predicting DL. CONCLUSION: The MMT and ULBT are good screening tests, followed by the TMD in predicting DL, while the RHTMD was the least accurate predictor. Because no single test has 100% predictive value, a combination of screening tests is advised in pediatrics for predicting DL.

Predictive Value of Modified Mallampati Test and Upper Lip Bite Test Concerning Cormack and Lehane's Laryngoscopy Grading in the Anticipation of Difficult Intubation: A Cross-Sectional Study at a Tertiary Care Hospital, Bhubaneswar, India.

Background and objective Many tests are at hand to predict difficult intubation preoperatively to prevent morbidity and mortality of unanticipated difficult intubation. The present study was conducted to evaluate and compare the efficacy of the modified Mallampati test (MMT) and upper lip bite test (ULBT) to foresee difficult intubation. Materials and methods After obtaining written informed consent, this prospective comparative observational study was conducted on 225 patients scheduled for elective surgery under general endotracheal anesthesia. Preoperative MMT and ULBT were performed. MMT Grade III, IV, and ULBT Grade IV were regarded as predictors of difficult intubation. The laryngoscopic view was graded as per Cormack and Lehane's laryngoscopic grading after induction of anesthesia by an experienced anesthesiologist ignorant of preoperative airway evaluation. Patients with Cormack and Lehane Class III and IV were regarded as difficult intubation. Sensitivity, specificity, and positive and negative predictive values of MMT and ULBT were computed. Agreement between two tests with the Cormack Lehane test was determined by the Kappa coefficient. Results In our research, the occurrence of difficult intubation was found to be 10.2% (23 cases of difficult intubation out of 225 patients). In our analysis, we found the sensitivity (95.5% vs. 95.4%), specificity (54.8% vs 50.0%), positive predictive value (91.6% vs 93.1%), and negative predictive value (39.1% vs 39.1%) were almost comparable between modified Mallampati test and upper lip bite test. Kappa coefficient for the upper lip bite test (0.492) was slightly higher as compared to modified Mallampati scoring (0.454), but both the values are highly statistically significant (p-value <0.001). Conclusion Both the upper lip bite test and modified Mallampati test are comparable with each other and since the upper lip bite test is easy to perform bedside test we recommend it to be used alone or in collaboration with other tests in assessing difficult airways.

Evaluation of the reliability of the upper lip bite test and the modified mallampati test in predicting difficult intubation under direct laryngoscopy in apparently normal patients: a prospective observational clinical study.

BACKGROUND AND AIMS: Difficult endotracheal intubation is one of the most challenging operations in anesthesia. How to better predict difficult airway and make corresponding preparations to reduce the occurrence of accidents is a difficult task faced by anesthesiologists every day. This study decide to evaluate the value of the Upper Lip Bite Test (ULBT) and the Modified Mallampati Test (MMT) in predicting difficult intubation under direct laryngoscopy and find out the most intuitive and simple method to predict difficult intubation under direct laryngoscopy in apparently normal patients. PATIENTS AND METHODS: This descriptive-analytical study was performed on 450 patients for elective surgery under general anesthesia requiring endotracheal intubation. The ULBT and MMT grading were evaluated preoperatively and Cormack and Lehane's (CL) classification was recorded on the day of surgery during intubation under direct laryngoscopy. The accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratio (LR), Youden index and area under ROC curve of ULBT and MMT respectively and in combination were calculated and compared. And the consistency between the total scores of ULBT and MMT combined in different ways and CL grading was counted. RESULTS: Of the 450 patients, 69 (15.3%) were classified as difficult cases of direct laryngoscopy. The accuracy, sensitivity, specificity, PPV and NPV of ULBT were 81.33, 11.59, 93.96, 25.81, 85.44%; and those the corresponding values for MMT were 66.22, 62.32, 69.29, 26.88 and 91.03%. A combination of ULBT and MMT did not improve the sensitivity in the sample tested. The combined total scores of ULBT and MMT in both ways were less consistent with CL grading in predicting difficult intubation under direct laryngoscopy. CONCLUSION: Based on findings of current study, we conclude that ULBT and MMT for difficult intubation have only poor to moderate discriminative power when used alone. The combination of the two tests in fractional form is also not a good predictor of difficult intubation under direct laryngoscopy. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR2100052987, Registered 07 November 2021, http://www.chictr.org.cn.

A Study to Evaluate Changes in Modified Mallampati Class in Patients Undergoing Spine Surgery in Prone Position.

BACKGROUND: Perioperative airway changes due to anesthesia and surgery could change a normal airway at induction to a risky airway at extubation. OBJECTIVES: The objective is to evaluate primarily the degree of airway changes, as quantified by the modified Mallampati (MMP) class, after spine surgery in the prone position. Secondary to assess the time required for these changes to revert back to the preoperative state and their correlation with other demographic and surgical variables. METHODS: The present prospective observational study was conducted in a tertiary care hospital after ethical approval and trial registration. Fifty ASA I and II patients aged 18-65 years of both sex and undergoing spine surgery in prone positions were included. Supine MMP grade was observed preoperatively and at one, two, four, 24, and 48 hours postoperatively. STATISTICAL ANALYSIS: IBM SPSS version 22 (IBM Corp, Armonk, NY) was used.Mean values were compared using paired t-tests and medians by the Wilcoxon test. The Spearman correlation was used to assess a relationship. The time for recovery was analyzed by Kaplan-Meir analysis. RESULTS: An increase in MMP grade was observed at one hour postoperatively in 46 (92%) patients. Changes reverted back in 45 (98%) patients by 24 hours postoperatively. A weak positive correlation with age, weight, body mass index, duration of surgery, perioperative drop in hemoglobin, and a moderate positive correlation with fluid administered and estimated blood loss was recorded. CONCLUSIONS: An increase in postoperative MMP occurs in the majority of patients undergoing prone position spine surgery which may persist up to 48 hours. So, more vigilance and caution are warranted should reintubation be needed postoperatively.

Comparison of modified mallampati classification with Cormack and Lehane grading in predicting difficult laryngoscopy among elective surgical patients who took general anesthesia in Werabie comprehensive specialized hospital - Cross sectional study. Ethiopia, 2021.

Background: Difficult laryngoscopy/intubation can cause a multitude of issues, including hypoxia, brain damage, and even death if not addressed swiftly. The Modified Mallampati test (MMT) is frequently used to predict difficult airway in patients with no clear difficult airway signal, despite its limited predictive power, in patients with no obvious difficult airway signal. Cormack and Lehane grading (CLG) is the gold standard, however it is not utilized before anesthesia. Objective: To compare modified Mallampati classification (MMC) with Cormack and Lehane grading in predicting difficult laryngoscopy among patients who took general anesthesia. Method: An institutionally based cross sectional survey study of 141 elective surgical patients with no obvious difficult airway sign was conducted from February to April 2021. The correlation between MMC and CLG was computed using spearman's correlation coefficient, and the area under the curve (AUC) for MMT was assessed using receiver operating characteristics (ROC) curve analysis. Result: The incidence of difficult laryngoscopy and intubation, respectively, was 14.9% and 9.2%. The Spearman correlation coefficient (ρ) was 0.330, with a significance level of 0.001. The AUCs for difficult laryngoscopy and intubation, respectively, were 0.705 and 0.726. MMT had 47.6% sensitivity and 93.3% specificity for difficult laryngoscopy and 53.8% and 91.4% specificity for difficult intubation, respectively. Conclusion: and Recommendation: There was little correlation between MMC and CLG. MMT sensitivity was similarly low. As a result, as part of the screening test for difficult airway, extra clinical tests are required.

Diagnosis of upper airways collapse in moderate-to-severe OSAHS patients: a comparison between drug-induced sleep endoscopy and the awake examination.

PURPOSE: Compare awake evaluation (modified Mallampati score-MMs, Müller maneuver-MM) to drug-induced sleep endoscopy (DISE) findings according to NOHL (nose-oropharynx-hypopharynx-larynx) classification in moderate-to-severe OSAHS patients. METHODS: 43 moderate-to-severe OSAHS patients referred to our ENT department were enrolled over a 2-year period. In this observational prospective study, each patient was evaluated by the same ENT team both in wakefulness and during pharmacologically induced sleep. Level and severity of the obstruction were described. RESULTS: The comparison of degree of collapsibility was statistically significative only at hypopharyngeal level: 41.8% of the patients showed a hypopharyngeal obstruction in wakefulness whereas 88.3% in DISE (p = 0.000). Laryngeal level was found in 18.6% patients during awake examination, conversely DISE demonstrated laryngeal obstruction in 4.6%. DISE identified significantly higher incidence of multilevel collapses (p = 0.001). However, the incidence of oropharyngeal obstruction in patients classified as MMs I and II was significantly higher in DISE compared to MM (p = 0.021). CONCLUSION: DISE is the best predictor of hypopharyngeal obstruction, whereas MM underestimates the severity of the collapse at this level. DISE is more reliable than MM to identify the obstruction in patients with MMs score I and II.

Clinical assessment of upper airway and its complications in Hunter syndrome.

BACKGROUND: Hunter syndrome (HS) is an X-linked, recessive, lysosomal storage disease caused by a deficiency of the lysosomal enzyme, iduronate sulfatase (IDS). It is characterized by multisystem accumulations of glycosaminoglycans and upper airway obstruction is one of the major causes of death. While the current disease severity classifications for HS are mainly based on the degree of neurocognitive impairment, its association with the level of upper airway obstruction has not been assessed. METHODS: A retrospective chart review of HS patients who were followed at the Jikei University School of Medicine was performed. Association between the degree of airway obstruction and the currently used disease severity scores was evaluated. RESULTS: We identified eight HS patients and they were enrolled in the study. The Modified Mallampati classification (MMC) score, used to predict difficulties for oropharyngeal procedures, was significantly correlated with the HS severity. It was also correlated with the Apnea-Hypopnea Index (AHI). No significant correlation between IDS enzymatic activity and the severity of HS disease was identified. CONCLUSIONS: Variable clinical expressivities exist in HS, but the risk of respiratory complications is likely to be associated with disease severity, assessed by the previously recognized neurocognitive function-based severity scoring systems. MMC can be a simple supplementary tool to evaluate disease severity as well as predict difficulties for oropharyngeal procedures and respiratory function complications in HS, such as sleep apnea.

Evaluation of thyromental height test in prediction of difficult airway in obese surgical patients: An observational study.

BACKGROUND AND AIMS: Thyromental height test (TMHT) has revealed good potentials for predicting difficult laryngoscopy view (DLV) in non-obese patients, but its accuracy in obese patients is not evident. This study aimed to assess the validity of TMHT as a predictor of DLV in obese surgical patients. METHODS: 105 patients, aged 18-60 years, with body mass index (BMI) >30 kg/m2, scheduled for elective surgeries under general anaesthesia with an endotracheal tube inserted using conventional laryngoscope were included. Airway was assessed with TMHT, modified Mallampati test (MMT), neck circumference (NC) and NC/TMHT ratio. The DLV was defined as Cormack-Lehane grade ≥3. The primary endpoint was the validity of TMHT as a predictor of DLV. The secondary endpoints were to compare the accuracy of TMHT with that of the NC, MMT and NC/TMHT ratio as predictors of the difficult airway. RESULTS: The BMI was 43.7 ± 6.6 kg/m2. The DLV cases were 23/105 (21.9%). The MMT, TMHT and NC/TMHT ratio had the best predictive ability of DLV with areas under receiver operating characteristic curve of 0.91, 0.92 and 0.80; at cut-off values >2, <47 mm and >7.9, respectively. MMT and TMHT were the only predictors of DLV by multivariate analysis. CONCLUSION: In obese surgical patients, TMHT is an excellent predictor of DLV when the cut-off value is <47 mm.

Avaliação do Escore de Wilson e do Teste de Mallampati modificado como preditores de difícil intubação orotraqueal: Estudo transversal / Evaluation of the Wilson risk-sum and the modified Mallampati Test as predictors of difficult orotracheal intubation: Cross-sectional study

INTRODUÇÃO: A consulta pré-anestésica é de extrema importância para o médico anestesiologista no planejamento do manejo das vias aéreas de pacientes sob o efeito de anestesia geral com intubação orotraqueal (IOT). OBJETIVO: Avaliar a sensibilidade, especificidade, valor preditivo positivo/negativo (VPP/VPN) de testes de predição de IOT difícil (Escore de Wilson - EW, e Teste de Mallampati modificado - TMM), em pacientes submetidos à anestesia geral, em hospital filantrópico do interior de Minas Gerais. MATERIAIS E MÉTODOS: Estudo descritivo transversal, por meio de fichas pré-anestésicas e transoperatórias, de pacientes submetidos à anestesia geral com IOT, entre os meses de janeiro (2019) e março (2020). RESULTADOS: Dos 440 pacientes, 56,1% necessitaram de IOT: média de idade de 49,9 anos (desvio padrão 18,6). A maioria foi classificada: TMM classe I e II; pontuação 0 a 2 no EW; distância esternomentoniana >12,5 cm, sugerindo IOT fácil. Apenas o TMM apresentou correlação com IOT difícil (p=0,045). Sensibilidade e especificidade dos testes respectivamente: TMM (54,6%;75,9%); EW (36,4% e 79,7%); baixo VPP (TMM: 9,5%; EW: 7,7%) e alto VPN (TMM: 97,3%; EW: 96,4%). Curva ROC: área sob a curva foi de TMM = 0,68; EW = 0,60. CONCLUSÃO: Apesar do TMM apresentar correlação significativa com a IOT difícil, não foi possível definir o melhor teste preditor. Ressaltamos que a sensibilidade e o VPP, de ambas as avaliações, ficaram abaixo daquilo que seria considerado adequado para um teste de rastreio e predição.

Introduction: A pre-anesthetic appointment is extremely important for the anesthesiologist when planning the management of the airways of patients under the effect of general anesthesia with orotracheal intubation (OTI). Objective: To evaluate the sensitivity, specificity, positive/ negative predictive value (PPV/NPV) of difficult OTI prediction tests (Wilson risk-sum ­ WRS, and Modified Mallampati Test - MMT) in patients undergoing general anesthesia in a philanthropic hospital in the countryside of the state of Minas Gerais. Materials and methods: Descriptive cross-sectional study using pre-anesthetic and transoperative records of patients submitted to general anesthesia with OTI between the months of January (2019) and March (2020). Results: Of the 440 patients, 56.1% required OTI: average age of 49.9 years (standard deviation 18.6). Most classified: MMT class I and II; score 0 to 2 on the WRS; sternomental distance greater than 12.5 cm, suggesting easy OTI. Only MMT showed statistical significance with difficult OTI (p=0.045). Sensitivity and specificity of the tests respectively: MMT (54.6%; 75.9%) WRS (36.4% and 79.7%) low PPV (MMT: 9.5%; WRS: 7.7%) and high NPV (MMT: 97.3%; WRS: 96.4%). ROC Curve: area under the curve was MMT = 0,68; WRS = 0,60. Conclusion: Although the MMT has a significant correlation with the difficult OTI, it was not possible to define the best predictor test. We emphasize that the sensitivity and PPV of both evaluations were below what would be considered adequate for a screening and prediction test.

Evaluation of different airway tests to determine difficult intubation in apparently normal adult patients: undergoing surgical procedures.

BACKGROUND: Inadequate maintenance of a patient's airway represents a major cause of anesthesia-related morbidity and mortality. This study was designed to evaluate common preoperative clinical tests to determine the risk of difficult endotracheal intubation in apparent "normal" adult patients undergoing surgical procedures. METHODS: A prospective observational cohort study was performed on 160 consecutive adult patients undergoing surgical procedures at an academic medical center in Jordan from 20 May 2019 until 11 February 2020. Preoperative assessment of airway risk stratification was performed by the following clinical tests: the mandible protrusion test (MPT), thyromental (TMD) and sternomental (SMD) distances, inter-incisor gap (IIG), and the modified Mallampati tests with tongue protrusion (MMT-TP) and without tongue protrusion (MMT-NTP). Grade C on the MPT, TMD ≤ 6 cm, SMD ≤ 12 cm, and MMT grades III and IV were considered to be predictors of difficult endotracheal intubations. A modified Cormack-Lehane grading (MCLG) of laryngoscopic views with backward, upward, and right-sided pressure on the thyroid and cricoid cartilages (BURP) maneuver was also documented, with grades 2B, 3, and 4 considered to be difficult airways for intubation. RESULTS: Fifteen patients (9.4%) were classified as MCLG 2B, 3, and 4, with age significantly associated with the MCLG grade (P = 0.028). The sensitivity and Youden's index of MMT-TP were found to be the lowest (40% and 0.29, respectively). The MPT was the most accurate and specific test (90.63 and 95.17%, respectively), with the highest PPV (50%), Youden's index (0.42), and area under the curve (AUC) (0.781). Bivariant analysis of MPT and the t-test of the mean TMDs and SMDs revealed significant associations between these airway tests and the difficulty of intubation (P values: < 0.001, 0.02, < 0.01, respectively). CONCLUSION: The MPT, with its highest accuracy, specificity, positive predictive value, and good sensitivity may be used as a routine screening test for preoperative prediction of difficult endotracheal intubations.

[The value of improved Mallampati grading combined with NoSAS in OSA screening].

Objective:To evaluate the value of improved Mallampati grading combined with NoSAS questionnaire in screening for obstructive sleep apnea （OSA）. Method:A total of 344 patients admitted to our hospital for sleep disorders were studied. All patients were measured for their height, weight, neck circumference and other parameters. NoSAS scores, improved Mallampati grading and polysomnography （PSG） were performed in these patients. According to AHI in PSG monitoring results, patients were divided into non-osa group （AHI<5） 93 cases and OSA group 251 cases. The OSA group were divided into mild （AHI 5-15）, moderate（AHI 16-30） and severe OSA group（AHI>30） according to the PSG result. The ROC curve was plotted to evaluate the screening value of NoSAS and improved Mallampati grading combined with NoSAS for OSA. Result:With the NoSAS score of 8 or 9 as cutoffs for analysis, the sensitivity for OSA was 0.733 and 0.701; the specificity for OSA was 0.538 and 0.624, respectively. The sensitivity and specificity of NoSAS combined with improved Mallampati grading for screening OSA were 0.813 and 0.710, respectively. Conclusion:As a new screening tool, NoSAS questionnaire is simple and convenient, and has certain screening value to OSA. The improved Mallampati grading combined with NoSAS questionnaire can obviously improve the screening sensitivity and specificity of Osa, and has higher application value.

Utility of the modified Mallampati grade and Friedman tongue position in the assessment of obstructive sleep apnea.

STUDY OBJECTIVES: The modified Mallampati (MM) grade and Friedman tongue position (FTP) are commonly used scales that assess the oropharynx during evaluation for obstructive sleep apnea (OSA). Though used by many practitioners, there is controversy in the literature regarding their practical utility. The goal of this review will be to review the history of how the MM and FTP were developed, to discuss current evidence for their usefulness in the workup of OSA, and to provide future direction to better understand their utility in the workup of OSA. METHODS: We searched the literature (PubMed) for the terms "modified Mallampati" and "Friedman tongue position." Articles were selected based on our study objectives emphasizing articles discussing the utility of MM and FTP in managing OSA. CONCLUSIONS: MM and FTP have the potential to be useful assessment tools in the evaluation of OSA. When performing this examination, it is important for physicians and other medical providers to understand the pitfalls of the MM and FTP including the potential difficulty in performing the exam and the lack of consistency between examiners in both the terminology and execution of this physical exam finding. Better methods to standardize the assessment are necessary to ensure consistent evaluation among individual examiners while at the same time keeping the method simple and convenient for wide use as a clinical screening tool.

The Relationship Between Modified Mallampati Score, Müller's Maneuver and Drug-Induced Sleep Endoscopy Regarding Retrolingual Obstruction.

OBJECTIVES: This study explored the correlation between clinical explorations, including modified Mallampati score and Müller's maneuver, with drug-induced sleep endoscopy (DISE) findings regarding retrolingual obstruction. METHODS: One hundred forty-two obstructive sleep apnea patients were enrolled in this prospective study. All of the patients received clinical explorations including modified Mallampati scoring and Müller's maneuver in the clinic. Drug-induced sleep endoscopy was further evaluated in the operating room. RESULTS: A significant relationship was noted between modified Mallampati score and retrolingual obstruction during DISE. In contrast, no significant relationship was noted between Müller's maneuver and DISE findings regarding retrolingual obstruction. CONCLUSIONS: A significant discrepancy existed between retrolingual airway collapse evaluated by modified Mallampati score and Müller's maneuver. Modified Mallampati score is more correlated with DISE regarding retrolingual obstruction compared to Müller's maneuver. It should therefore be used as an initial evaluation of retrolingual obstruction when DISE is unavailable.

Diagnostic accuracy of radiology (CT, X-ray, US) for predicting difficult intubation in adults: A meta-analysis.

OBJECTIVE: The aim of this study was to evaluate the overall accuracy of radiological measurements in prediction of difficult airway and compare the diagnostic value between the radiological measurements and the modified Mallampati score through a meta-analysis of published studies. METHODS: A comprehensive electronic search of related literature was performed in PubMed, Embase, Cochrane Library and China National Knowledge Infrastructure. Meta-DiSc 1.4 and STATA 12.0 were selected for data analysis, and QUADAS-2 tool was used to assess the quality of included studies. Difficult airway was defined as Cormack-Lehane III-IV. Data from selected studies were pooled to yield summary sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, as well as summary receiver operating characteristic curve. RESULTS: A total of 17 studies dating up to November 2017 with 8779 individuals were enrolled in the present study. Heterogeneity existed in the non-threshold effect, but not in the threshold effect. Subgroup analyses based on radiological methods were conducted. The pooled diagnostic characteristics in the computed tomography subgroup were as follows: sensitivity 0.75 (95%CI, 0.64-0.84), specificity 0.75 (95%CI 0.68-0.81), PLR 3.19 (95%CI 1.91-5.32), NLR 0.38 (95%CI 0.23-0.64), DOR 11.74 (95% CI, 4.19-32.86) and AUC 0.8424 with Q* index 0.7741. In the X-ray subgroup, the sensitivity was 0.78 (95%CI, 0.73-0.82), the specificity was 0.88 (95%CI, 0.87-0.89), PLR was 5.03 (95%CI, 2.44-10.37), NLR was 0.27 (95%CI, 0.22-0.33), DOR was 23.18 (95%CI, 8.81-60.95) and AUC was 0.8970 with Q* index 0.8280. The corresponding values for the ultrasound subgroup were 0.69 (95%CI, 0.63-0.74) for sensitivity, 0.84 (95%CI, 0.82-0.85) for specificity, 6.25 (95%CI, 3.81-10.27) for PLR, 0.36 (95%CI, 0.27-0.47) for NLR, 22.26 (95%CI, 10.45-47.41) for DOR, 0.8942 for AUC with Q* index 0.8251. The pooled sensitivity, specificity and PLR of the modified Mallampati score were 0.61 (95%CI 0.56-0.66), 0.63 (95%CI 0.61-0.64) and 2.11 (95%CI 1.71-2.61) which were significantly lower than that of radiographic methods. CONCLUSIONS: The results indicated that the diagnostic value of CT, X-ray and US was much better than that of modified Mallampati score. Ultrasound had diagnostic indices and the area under curve similar to those of CT and X-ray in predicting difficult airway. Considering being easy, readily availability, low cost, and free from radiological hazards, it can be considered as prior diagnostic strategy in this condition.