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Validation of modified Mallampati test with

addition of thyromental distance and
sternomental distance to predict difficult
endotracheal intubation in adults

Article in Indian journal of anaesthesia March 2014

DOI: 10.4103/0019-5049.130821 Source: PubMed


2 160

4 authors, including:

Rajiv Khandekar
King Khaled Eye Specialist Hospital


All in-text references underlined in blue are linked to publications on ResearchGate, Available from: Rajiv Khandekar
letting you access and read them immediately. Retrieved on: 20 October 2016
ISSN : 0019-5049

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Indian Journal of Anaesthesia Volume 58 Issue 2 March-April 2014 Pages 111-???

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Validation of modified Mallampati test with addition
of thyromental distance and sternomental distance
to predict difficult endotracheal intubation in adults

Address for correspondence: Bhavdip Patel, Rajiv Khandekar, Rashesh Diwan1, Ashok Shah1
Dr.Rajiv Khandekar, Department of Anesthesia, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia, 1Department of
Department of Research, King Anesthesia, SAL Hospital, Ahmedabad, Gujarat, India
Khalid Eye Specialist Hospital,
POB7191, Riyadh11462,
Saudi Arabia. ABSTRACT
Background and Aims: Intubation is often a challenge for anaesthesiologists. Many parameters
assist to predict difficult intubation. The present study was undertaken to assess the validity of
different parameters in predicting difficult intubation for general anaesthesia (GA) in adults and
effect of combining the parameters on the validity. Methods: The anaesthesiologist assessed
oropharynx of 135 adult patients. Modified Mallampati test (MMT) was used and the thyromental
distance (TMD) and sternomental distances (SMD) for each of the patients were also measured.
The Cormack and Lehane laryngoscopic grading was assessed following laryngoscopy. The
validity parameters such as sensitivity, specificity, false positive and negatives values, positive
and negative predictive values were calculated. The effect of combining different measurements
on the validity was also studied. Univariate analysis was performed using the parametric method.
Access this article online Results: The study group comprised of 135patients. The sensitivity and specificity of MMT were
Website: 28.6% and 93%, respectively. The TMD (<6.5 CM) had sensitivity and specificity of 100% and
75.8%, respectively. The SMD (<12.5 CM) had sensitivity and specificity of 91% and 92.7%,
DOI: 10.4103/0019-5049.130821
respectively. Combination of MMT grading and TMD and SMD measurements increased the
Quick response code
validity (sensitivity of 100% and specificity of 92.7%). Conclusion: MMT had high specificity.
The validity of combination of MMT, SMD and TMD as compared to MMT alone was very high
in predicting difficult intubation in adult patients. All parameters should be used in assessing an
adult patient for surgery under GA.

Key words: Anaesthesia, endotracheal intubation, modified Mallampatti test, validity

INTRODUCTION incisor-gap aid in assessing a difficult endotracheal

intubation. The literature has shown uses of different
Difficult or failed endotracheal intubations are one of preoperative measurement parameters in predicting
the leading causes of anaesthesiarelated morbidity difficult intubation. However, limited information is
and mortality. The incidence of difficult endotracheal available on effect of combining these parameters in
intubation is 3.2%[1] and includes failed and difficult enhancing the validity parameters.
intubation, difficult laryngoscopy or difficult mask
ventilation. This risk can be reduced if difficult airway We undertook a study to compare MMT grading before
is evaluated preoperatively.[2] Modified Mallampati surgery to the Cormack Lehanes grading(CLG) of
grading (MMT) is a widely used preoperative difficulty in intubation during anaesthesia. We also
evaluation.Other parameters of preoperative evaluated the role of adding other measurements like
airway assessment including, thyromental distance, thyro mental distance(TMD) and manubrium sterni to
sternomental distance, cervical mobility and Inter- mentum distance(SMD) in enhancing the validity of

How to cite this article: Patel B, Khandekar R, Diwan R, Shah A. Validation of modified Mallampati test with addition of thyromental distance
and sternomental distance to predict difficult endotracheal intubation in adults. Indian J Anaesth 2014;58:171-5.

Indian Journal of Anaesthesia | Vol. 58 | Issue 2 | Mar-Apr 2014 171

Patel, etal.: Validity of MMT, TMD and SMD to predict difficult endotracheal intubation

MMT in predicting difficult intubation(based on CLG) An investigator performed a standard preoperative

in patients aged 15years and older. assessment and recorded the findings using a pretested
data collection form. Another investigator who was
METHODS not involved in preoperative assessment performed
laryngoscopy without knowing the MMT outcomes
The hospital research committee granted approval for of the patient. He documented the level of difficulty
this study. The study was conducted in 135patients by grading the patient just prior to intubation and
in a multispecialty hospital between November the actual difficulty during intubation using CLG.
and December 2010, aged 15 to 80years requiring Astatistician who was involved in analyzing the data
general anaesthesia with endotracheal intubation. In was blinded to both the preoperative and intraoperative
our hospital, children aged 15years and older were results.
grouped as adults. Hence for logistic reasons, we
included patients aged 15years and above as adults. Patients remained on an empty stomach for eight
Informed written consent was obtained from all hours and glycopyrrolate 4g/kg and midazolam
patients. Patients with swelling, scars, contractures 20 g/kg was given intravenously 15minutes before
in front of the neck and those with pathological surgery. For general anaesthesia, patients were
conditions making intubation a difficult task were given oxygen for 3 to 5minutes. Subsequently,
excluded from the study. Data were collected on age, intravenous injection of fentanyl sodium(2ug/kg)
gender, weight, the type of surgical procedure and was administered, followed by a slow injection of
anaesthesia physical status(American Association of propofol(2mg/kg). After confirming that the patient
Anesthesiologists(ASA)). could be ventilated by mask(100% oxygen given
for 23minutes), 1.5mg/kg bolus of intravenous
The anaesthesiologist and patients sat at eye level succinylcholine was administered. Neuromuscular
and thepatient opened his/her mouth as wide as relaxation was monitored and on confirmation,
possible with the tongue protruding. Depending on intubation was attempted. Before laryngoscopy, the
the visualization of the oropharyngeal structures, the head was extended on a 10cm pack and neck was
patients were graded according to the MMT.[3] Grading flexed to achieve the modified Jackson position. The
the oropharynx was based on protruding maxillary laryngoscope was introduced and larynx visualized.
teeth(overbite). With the patient in the sitting position The degree of visualization of larynx was classified
with maximal extension of the head, the neck was according to the Cormack and Lehane laryngoscopic
palpated for thyroid notch. The distance between grading.[2]
the thyroid notch and symphysis menti(TMD) was
measured in centimetres with a measuring tape. A senior anaesthesiologist with at least two years of
With the patient in the sitting position and maximal experience performed intubation. If on two or more
extension of the head and the mouth closed, the straight attempts, inadequate glottis was visible or not visible
distance between the upper border of the manubrium at all, it was considered a difficult intubation. Different
sterni and the bony point of mentum(SMD) was size of laryngoscope blades, McCoy blades, stylet,
measured.[4] If TMD was less than 6.5cm, it was bougie, various size of mask, small size of endotracheal
considered as predictor for difficult intubation. If SMD tubes, LMA, Combitube and Cricothyrotomy kit
was less than 12.5cm, we considered it a predictor of were part of difficult airway cart. Failed intubation
a difficult intubation. was defined as inability to insert a tracheal tube
from the oropharynx into the trachea. Details of the
Of the 5,000patients per month that undergo maneuvers during intubation were documented such
surgery in our institution, we assumed that 60% as application of external pressure over the larynx, use
could correctly predict a difficult intubation through of an extralarge blade of laryngoscope or stylet.
preoperative assessment.[5] For 95% confidence
intervals and 10% precision with clustering effect of To assess the validity of MMT and TMD and
1.5 due to different operation theatres(as the study SMD score, we calculated sensitivity, specificity,
sites), we required 136patients in this validity false positive, false negative, positive predictive
study. To calculate the sample size, we used Open and negative predictive values. The difficulty in
Source Epidemiologic Statistics for Public Health, endotracheal intubation for anaesthesia was the gold
Version2.3.1.(Open Epi 2.3.1Sweden, Denmark). standard for assessing validity. As MPG is a categorical

172 Indian Journal of Anaesthesia | Vol. 58 | Issue 2 | Mar-Apr 2014

Patel, etal.: Validity of MMT, TMD and SMD to predict difficult endotracheal intubation

variable, we used a 22 table to assess the validity in 41 cases. Eleven of these cases were difficult
parameters. The TMD and SMD measurements were intubation. All 94 cases in which the TMD
continuous variables. Hence, the Receiver Operating was6.5cm, the intubation was performed without
Characteristic(ROC) curves were plotted to associate any difficulty. Thus the sensitivity and specificity of
the sensitivity and the specificity. We also used the TMD measurement was 100% and 75.8%, respectively.
standards of TMD <6.5 cm and SMD <12.5 cm to
define an abnormal length of the oropharynx that The SMD was<12.5cm in 19cases. Ten of these
could negatively affect intubation. By clubbing these cases were a difficult intubation. Of these cases
parameters to the MMT, we assessed the changes in with SMD12.5cm, in only 1 out of 116cases the
the validity parameters. The Statistical Package for intubation was difficult. Thus the sensitivity and
Social studies(SPSS version12; IBM Corp., NewYork, specificity of SMD measurement was 91% and 92.7%,
NY, USA) was used for univariate analysis with the respectively.
parametric method.
By combining the parameters of TMD and SMD,
RESULTS we could increase the sensitivity and specificity
parameters of predicting difficult intubation to 100%
One hundred and thirty five patients(71males and and 92.7%, respectively [Table 2].
64females) participated in our study. The mean age
of the participants was 29.71.4years. The mean By combining MMT and(TMD+SMD) parameters,
weight of the participants was 54.911.1kg. Only the sensitivity and specificity of predicting a difficult
two patients were graded ASA I anaesthesia risk and intubation increased to 100% and 93%, respectively.
the remaining 133cases were ASA II. Laparoscopic
surgeries were planned for 61patients. Other surgeries DISCUSSION
included orthopaedic(13patients), ear nose and
throat(ENT)(7patients), urological(12patients) and By combining parameters thyromental and
general surgeries(42patients). steromental distance measurement to the modified
Mallampati Test(MMT) outcomes, the sensitivity to
The incidence of difficult intubation was 8.1%(95% predict difficult intubation increased from 27% to
CI: 3.512.7)]. The mean age of patients classified as 100% and the specificity remained 93%. In view of
difficult intubation was 40.3years[15.0years standard high predictive values of the combined test, our study
deviation(SD)]. The mean age of patients not classified results could be applied to adult population with ASA
as difficult intubation was 30.7years(10.7years II and II undergoing surgery under general anaesthesia.
SD). The age difference in two groups was not
statistically significant[Mean difference=9.6years; Table1: Validity of modified Mallampati test method of
predicting difficulty in endotracheal intubation
95% CI:0.619.8; P>0.05].
Grade Difficulty in Total
endotracheal intubation
The mean weight of patients classified under difficult Difficult Not difficult
intubation was 60.3kg(13.1kg SD). The mean weight Modified III and IV 2 9 11
of patients not classified as difficult intubation was Mallampati test I and II 5 119 124
54.4kg(10.8kg SD). The weight difference between 7 128 135
Sensitivity=2/7100=28.6, Specificity=119/128100=93.0, False
groups was not statistically significant[Mean positive=5/7100=71.4, False negative=9/128100=7.0, Positive predictive
difference=5.86kg; 95% CI:1.012.9; P>0.05]. value=2/11100=18.2, Negative predictive value=119/124100=96.0

The validity of MMT in predicting a difficult Table2: Validity of combining all parameters in
intubation was reviewed[Table1]. The sensitivity of predictingdifficult endotracheal intubation
Grade Difficulty in Total
this assessment procedure was 27%. The sensitivity endotracheal intubation
and specificity values of the TMD and SMD parameters Difficult Not difficult
to predict difficult intubation were studied with ROC All predictors II and III 7 4 11
curve. Both TMD and SMD parameters were highly together I 1 123 124
MMT+TMD+SMD 8 127 135
sensitive[Figures1 and 2].
Sensitivity=7/8100=87.5%, Specificity=123/127100=96.9%, False
positive=1/8100=12.5, False negative=4/127100=3.1%, Positive predictive
The TMD of <6.5 cm predicted a difficult intubation value=7/11100=63.6%, Negative predictive value=123/124100=99.2%

Indian Journal of Anaesthesia | Vol. 58 | Issue 2 | Mar-Apr 2014 173

Patel, etal.: Validity of MMT, TMD and SMD to predict difficult endotracheal intubation



6 6
W \

Figure1: Validity of ThyroMental Distance in predicting difficulty Figure2: Validity of Sterno Mental Distancein predicting difficulty
in endotracheal intubation. Sensitivity=90% and specificity=90% in endotracheal intubation. Sensitivity=80% and specificity=90%

The incidence of a difficult laryngoscopy or intubation The validity parameters could be affected by the rate
varies from 1.5 to 13% and failed intubation has been of outcome variables prevalent in the population
identified as one of the causes of death or permanent under study.[10] It was 8.1% in our study. Langaron
brain damage related to anaesthesia.[2] Problems etal. found it to be 6.1%.[4] The incidence ranged
in airway management can be predicted based on between 1.5% and 8%.[11] The higher rate of difficult
previous anaesthesia records, the medical history intubation in our study with Indian population is
of the patients and a physical examination. Several worth noting, as we had not specifically included
radiologic measurements were reported to be bariatric cases.[12] Perhaps, racial differences
associated with a difficult intubation. However, resulting in different anatomical features of
simple clinical examination is a widely used method oropharynx and larynx could be responsible for
to predict difficult intubation. variability of difficult intubation among different
The incidence of difficult intubation in our study
was 8.3%. The validity of MMT to predict a difficult Age and weight in our study was not different among
intubation was low. The addition of TMP and SMT those who had a difficult intubation compared to those
to MMT for preoperative assessment improved the who did not have a difficult intubation. Therefore, we
validity of predicting difficult intubations. did not attempt to use them as predicting factors. Sheff
etal.[11] also found that body mass index(BMI) was
In a study with a large sample size, researchers noted not a predictor of difficult intubation. Older age was a
that the combination of MMT and TMD were good predictor of difficult intubations in Turkey.[13]
predictors of a difficult laryngoscopy in the Thai
population.[5] However, they had used TMD<6cm as The validity of the MMT and TMD varies widely. The
a parameter instead of<6.5cm used in the current sensitivity ranged from 42 to 91% while specificity
study. In another study, investigators assessed ranged between 66% and 84%.[14] The TMD although
Chinese females who were pregnant and those who is a more valid measurement for predicting a difficult
were not pregnant and found that the combination of intubation and it is influenced by height of patient.[15,16]
predictive variables could improve the validity.[6] A The lack of data related to height due to clerical error
study from the USA found that by using as many as in data management in our study was a limitation. We
ten measurements, aggregate set of variables improved could not calculate BMI and role of height in predicting
predictability of a difficult intubation.[7] Iohom etal. a difficult intubation.
performed a study in Ireland and noted that the
validity of positive predictive value of MMT increased Tripathi etal. used5cm TMD value whereas Khan
from 27 to 100% after combining other predictors.[8] etal. used SMD value of 13cm in their respective
In contrast, the combination of MMT and TMD was studies.[17,18] This was different from the measurement
not an adequate predictor of a difficult intubation in a of 6.5 cm for TMD and 12.5 cm for SMD used
study by Koh etal.[9] in our study. Alack of standardized TMD and SMD

174 Indian Journal of Anaesthesia | Vol. 58 | Issue 2 | Mar-Apr 2014

Patel, etal.: Validity of MMT, TMD and SMD to predict difficult endotracheal intubation

values to categorize the patients has resulted in wide a paradigm change. Anesthesiology 2012;117:122333.
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6. Magalhes E, Oliveira MarquesF, Sousa Govia C, Arajo
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LadeiraLC, LagaresJ. Use of simple clinical predictors on
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We therefore plotted ROC of TMD and SMD. This has obese patients. Rev Bras Anestesiol 2013;63:2626.
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18. KhanZH, MohammadiM, RasouliMR, FarrokhniaF, KhanRH.
The diagnostic value of the upper lip bite test combined with
We thank the administrators of Sal hospital for permission
sternomental distance, thyromental distance, and interincisor
to undertake this study. We thank Dr.Mukesh Vakil for his distance for prediction of easy laryngoscopy and intubation:
guidance and encouragement. Aprospective study. Anesth Analg 2009;109:8224.
19. ScheipersU, PerreyC, SiebersS, HansenC, ErmertH.
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