An abnormal epiglottis but an easy intubation
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Abstract:
The Mallampatti test was devised as a simple bedside examination to predict the likelihood of difficult intubation. We would like to report a case of unusual anatomy seen when performing this test. The on-call anaesthetist was requested to provide anaesthesia for an otherwise healthy 33-year-old woman requiring an urgent Caesarean section. A Mallampatti test was performed as part of the pre-operative assessment and a 2-cm mass was immediately evident protruding from the base of the tongue. Closer inspection revealed this to be the patient's epiglottis (Figure). The patient received a general anaesthetic for the operation and was noted to be an extremely easy intubation. There were no intra- or postoperative complications. In their paper describing what has now come to be known as the Mallampatti test, Mallampatti et al. [1] printed an illustration of a Mallampatti Class 1 patient in whom the faucial pillars, soft palate and uvula are visible. The illustration also shows a small part of the epiglottis seen at the base of the tongue, although no mention is made of this in the text. We have been unable to find any case in the literature where an epiglottis is visible on performing a Mallampatti test, although there is a case report of an elongated epiglottis with an unusual angle causing a difficult intubation [2].Keywords:
Epiglottis
Soft palate
Background: It has been observed that laryngoscopy and intubation leads to profound cardiovascular effects along with an increase in catecholamine concentrations. Multiple studies have been conducted to attenuate the same. McCoy blade has been found to decrease this pressor response as compared to the Macintosh blade used routinely. Therefore, a comparative study of heart rate (HR) and mean arterial pressure (MAP) changes during laryngoscopy and intubation using these two blades was conducted to establish the same. Methods: The study included 200 patients divided into two groups of 100 each. Laryngoscopy and intubation was performed either with Macintosh or McCoy blade. The HR and MAP were recorded at every 1 minute interval during laryngoscopy and intubation for 5 minutes. Apart from above observations, Mallampatti classification (MPC), Cormack and Lehane classification (C& L) and time required for intubation were noted. Results: There was no difference in baseline HR and MAP in both the groups i.e. Macintosh (MK) and McCoy (MY) . The percentage rise from baseline HR and MAP in MK group was highly significant during laryngoscopy and intubation and 1 minute after that as compared to MY group. Similarly, comparison of HR and MAP changes between both the groups revealed highly significant decrease in the parameters in MY group, during laryngoscopy and intubation and 1 minute after the procedure. No other complications of laryngoscopy & intubation were observed in our study. Conclusion: McCoy blade, primarily devised for difficult intubation has additional benefit of alleviating the pressor response to laryngoscopy and intubation. We recommend its use in patients with cardiovascular compromise, raised intracranial tension (ICT), apart from its established indications. Abbreviations: HRHeart Rate, MAPMean Arterial Pressure, ICT – Intracranial tension
Pressor response
Mean arterial pressure
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Abstract Predicting difficult laryngoscopy is an essential component of the airway management. We aimed to evaluate the use of anterior neck soft tissue measurements on computed tomography for predicting difficult laryngoscopy and to present a clear measurement protocol. In this retrospective study, 281 adult patients whose tracheas were intubated using a direct laryngoscope for thyroidectomy were enrolled. On computed tomography, the distances from the midpoint of the thyrohyoid membrane to the closest concave point of the vallecular (membrane-to-vallecula distance; dMV), and to the most distant point of the epiglottis (membrane-to-epiglottis distance; dME) were measured, respectively. The extended distances straight to the skin anterior from the dMV and dME were called the skin-to-vallecula distance (dSV) and skin-to-epiglottis distance (dSE), respectively. Difficult laryngoscopy was defined by a Cormack-Lehane grade of > 2. Difficult laryngoscopy occurred in 40 (14%) cases. Among four indices, the dMV showed the highest prediction ability for difficult laryngoscopy with an area under the receiver operating characteristic curve of 0.884 (95% confidence interval 0.841–0.919, P < 0.001). The optimal dMV cut-off value for predicting difficult laryngoscopy was 2.33 cm (sensitivity 75.0%; specificity 93.8%). The current study provides novel evidence that increased dMV is a potential predictive indicator of difficult laryngoscopy.
Epiglottis
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Summary Background Some techniques used to achieve intubation in children predicted to have a difficult airway do not involve direct laryngoscopy or assessment of the laryngeal grade. Direct laryngoscopy may therefore be performed immediately after intubation to provide a record for future anesthetics. It is unknown whether this postintubation grade accurately reflects the standard laryngeal grade in this group. Aim The aim of the study was to identify those children who were predicted to be a difficult intubation and to perform direct laryngoscopy before and after intubation. We set out to ascertain if direct laryngoscopy performed after intubation could accurately predict the standard un‐intubated laryngeal grade in this group. Methods All children presenting for general anesthesia who were clinically predicted to be a difficult intubation were considered for this study and prospectively recruited. After induction of anesthesia, one study anesthetist performed direct laryngoscopy before and another study anesthetist then performed direct laryngoscopy after intubation. These laryngeal grades were then compared. Results A total of 21 children were successfully recruited and studied, and all patients were successfully intubated. Overall, the postintubation grade did not reliably reflect the standard grade, but did not differ by more than one grade in any patient. In one‐third of subjects, the postintubation grade was equal to the standard grade, in one‐third it was a grade ‘easier’ and in one‐third a grade ‘harder’. Conclusion Assessment and documentation of a postintubation laryngeal grade does not appear to provide reliable information for future anesthetics and may even have the potential to be misleading. Any such documentation should always refer to the presence of an endotracheal tube and be interpreted with caution.
Laryngeal Diseases
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A new practical classification of laryngeal view at laryngoscopy is presented and evaluated. The best laryngeal view obtained with or without anterior laryngeal pressure is recorded. The laryngeal view is easy ( E )when the laryngeal inlet is visible. The view is restricted ( R ) when the posterior glottic structures (posterior commissure or arytenoids) are visible or the epiglottis is visible and can be lifted; this includes some grade 2 and some grade 3 views as classified by Cormack and Lehane. A difficult ( D ) view is present when the epiglottis cannot be lifted or when no laryngeal structures are visible. Five hundred patients were studied. Laryngoscopy, with the patient anaesthetised and paralysed, was performed with a Macintosh laryngoscope. If the vocal cords were not visible, a gum elastic bougie was used to aid intubation. Other aids were used only if this did not allow intubation. Each laryngeal view was graded according to the new classification and that of Cormack and Lehane. Intubation was timed and the equipment needed to facilitate intubation was recorded. The new classification stratified increasing difficulty with intubation (time for intubation longer and increasingly complex methods needed) better than the Cormack and Lehane classification. The new classification is as sensitive and more specific than the Cormack and Lehane classification in predicting difficult intubation. It is also more sensitive and more specific in predicting easy intubation.
Epiglottis
Anterior commissure
Posterior commissure
Laryngeal Diseases
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Background: Laryngoscopy and endotracheal intubation is an integral part of general anesthesia. Endotracheal intubation involving conventional laryngoscopy produces a haemodynamic changes associated with increased heart and blood pressure. The aim of the present study was to compare the hemodynamic changes that occur during and after endotracheal intubation with either a conventional (Macintosh) laryngoscope or a video laryngoscope in patients who are ASA grade I and II.Methods: After getting approval from ethics committee and consent form from each patients 120 patients with age between 18-65 years of ASA-I, II grade were included in the study. They were divided into two groups. Group A was underwent with tracheal intubation with the Macintosh blade (size 3 blade and size 4) and group B with AWS (Pentax) video laryngoscope. The time taken to perform endotracheal intubation and haemodynamic changes associated with intubation were noted in both the groups at different time points.Results: The duration of laryngoscopy and intubation was significantly longer in group B (video laryngoscopy) when compared to group A patients. However, haemodynamic changes did not showed any significant differences between the groups.Conclusions: Video laryngoscopy did not offer any advantages in terms of haemodynamic response to laryngoscopy and intubation in patients when compared with conventional ones.
Haemodynamic response
Endotracheal intubation
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Background An adult mare, presented to the University of Tennessee’s Veterinary MedicalCenter because of chronic, persistent coughing and abnormal respiratory noise,was found, during endoscopic examination of its nasopharynx and larynx, to havehypoplasia of the caudal fourth of its soft palate and an aryepiglottic fold entrapment.The mare had developed chronic discharge of feed from the nares after the aryepiglotticfold entrapment was relieved with a laser, using endoscopic guidance. Methods The mare received a laryngeal tie forward procedure to ameliorate discharge of feedfrom the nares by decreasing the gap between the apex of the epiglottis and thesoft palate. Results The distance between the epiglottis and the soft palate appeared to have beenreduced during endoscopic examination of the nasopharynx, and the horse nolonger experienced discharge of feed from the nares or persistent coughing. Thehorse continued to produce abnormal respiratory noise but was able to be usedfor trail riding. Discussion The tie-forward procedure should be considered as a treatment to ameliorate signs of hypoplastic soft palate in horses, if the palatal defect is short.
Soft palate
Epiglottis
Hard palate
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The screening tests used for pre-operative evaluation of airway to predict difficult laryngoscopy and intubation have variable diagnostic accuracy. The unanticipated poor laryngeal view is gold standard for defining difficult intubation. We aimed to find out the prevalence of difficult laryngoscopy and intubation, which airway parameter better predicts difficult intubation and whether difficult laryngoscopy is associated with difficult intubation or not.This analytic cross sectional study was conducted in 665 ASA I/II adult patients, aged 18-65, without obvious airway pathology undergoing elective surgery under general anesthesia. The pre-operative screening tests included mouth opening, modified mallampatti, ratio of height to thyromental distance, sternomentaldistance and upper lip bite test. Cormack-Lehane grade III/ IV was defined as difficult laryngoscopy and potentially difficult intubation. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy and area under curve at 95% confidence interval was calculated for all five screening tests.The prevalence of difficult laryngoscopy and intubation was 6.6% (44 cases). The upper lip bite test because of its highest specificity, positive predictive value, negative predictive value, accuracy and area under curve (99.7%; 93.9%; 99.7%; 95.2%; 85.1% respectively) with moderate level of sensitivity (70.5%) was better predictor of difficult intubation than other tests. The difficult laryngoscopy was associated with difficult intubation (p=0.00).The prevalence of difficult laryngoscopy and intubation was 6.6%.The upper lip bite test was a better predictor of difficult intubation and there was a significant association of difficult laryngoscopy with difficult intubation.
Gold standard (test)
Elective surgery
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Epiglottis
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Background An adult mare, presented to the University of Tennessee’s Veterinary MedicalCenter because of chronic, persistent coughing and abnormal respiratory noise,was found, during endoscopic examination of its nasopharynx and larynx, to havehypoplasia of the caudal fourth of its soft palate and an aryepiglottic fold entrapment.The mare had developed chronic discharge of feed from the nares after the aryepiglotticfold entrapment was relieved with a laser, using endoscopic guidance. Methods The mare received a laryngeal tie forward procedure to ameliorate discharge of feedfrom the nares by decreasing the gap between the apex of the epiglottis and thesoft palate. Results The distance between the epiglottis and the soft palate appeared to have beenreduced during endoscopic examination of the nasopharynx, and the horse nolonger experienced discharge of feed from the nares or persistent coughing. Thehorse continued to produce abnormal respiratory noise but was able to be usedfor trail riding. Discussion The tie-forward procedure should be considered as a treatment to ameliorate signs of hypoplastic soft palate in horses, if the palatal defect is short.
Soft palate
Epiglottis
Hard palate
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Study Objective Video laryngoscopy has primarily been developed to assist in difficult airways. Using video laryngoscopy in pediatric airway management is an up-and-coming topic. The aim of the presented study was to compare the intubation conditions obtained when using the C-MAC video laryngoscope with Miller blades sizes 0 and 1 for standard direct laryngoscopy and indirect laryngoscopy in children weighing less than 10 kg. Design This was a prospective study. Setting The study was performed in a university hospital. Patients Following ethical approval, 86 infants weighing less than 10 kg and undergoing surgery under general anesthesia were studied prospectively. Intervention Indirect and direct laryngoscopy either with C-MAC Miller blade size 0 or size 1. Measurements First, direct laryngoscopy was performed, and the best obtained view was graded without looking at the video monitor. A second investigator blinded to the view obtained under direct laryngoscopy graded the laryngeal view on the video monitor. Time to intubation, intubation conditions, and intubation attempts were recorded. Results In infants less than 10 kg, intubation conditions were excellent. There were no significant differences between the use of Miller blade 0 or 1 in reference to Cormack-Lehane grade, time to intubation, time to best view, or intubation attempts. Comparing direct and indirect intubation conditions using either Miller blade 0 or 1 revealed that the use of indirect laryngoscopy provided a significantly better view ( P < 0.05) of the vocal cords. In 3 infants weighing more than 8 kg, the Miller blade 0 was described as too short and narrow for intubation. Conclusions Both devices allowed for an excellent visualization of the vocal cords.
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