Diagnostic accuracy of Modified Mallampati Test grading with and without phonation for predicting Difficult laryngoscopy and intubation in Adult Surgical Patients-A cross sectional study

The American Society of anaesthesiologists (ASA) has continually emphasized the significance of preoperative airway examination and developing appropriate procedures and equipment for managing potentially difficult airways .

Difficult Airway is the clinical scenario where an anaesthesiologist with traditional training has trouble with mask ventilation, tracheal intubation, or both with one or more recognized techniques.

Inability to maintain a patent airway, Oxygenation and ventilation can quickly result in hypoxemia, brain injury, or death, especially in patients with low oxygen reserves, such as the obese, peadiatric, or critically unwell patients . Hence, early detection of a potentially problematic airway is critical to ensure patient safety.

Poorly managed Unanticipated difficult airway is a major source of morbidity and mortality.  The Fourth National Audit Project  in the United Kingdom discovered that inadequate preoperative airway assessment was a major factor in airway-related complications, many of which resulted in hypoxic brain injury or death . So improved prediction algorithms could greatly minimise this burden.

The Modified mallampati Test (MMT) is a popular bedside tool for difficult airway assessment since it is simple to perform, non-invasive, and inexpensive

Despite its broad use, Modified mallampati predictive value has remained variable.  Several factors influence its accuracy, including the patient’s participation, tongue protrusion, position of the patient and phonation. However, no standardized approach exists, and the effect of these variances on predicting accuracy has not been well investigated .

Samsoon and Young updated the original Mallampati test from three to four classes .Modified mallampati Test is often conducted in sitting with head in neutral position and instructing the patient to open their mouth and protrude their tongue without phonation.

When phonated ("say ah"), it improves the mallampati score as it flattens the tongue , contracts the levator veli palatine muscle and pulls the soft palate upward and backwards. This anatomical relationship explains the correlation and laryngoscopic view on phonation . Hence here phonation is added as a parameter in the test to know its efficacy on mallampati examination.

The American Society of anaesthesiologists (ASA) has continually emphasized the significance of preoperative airway examination and developing appropriate procedures and equipment for managing potentially difficult airways .

Difficult Airway is the clinical scenario where an anaesthesiologist with traditional training has trouble with mask ventilation, tracheal intubation, or both with one or more recognized techniques.

Inability to maintain a patent airway, Oxygenation and ventilation can quickly result in hypoxemia, brain injury, or death, especially in patients with low oxygen reserves, such as the obese, peadiatric, or critically unwell patients . Hence, early detection of a potentially problematic airway is critical to ensure patient safety.

Poorly managed Unanticipated difficult airway is a major source of morbidity and mortality.  The Fourth National Audit Project (NAP4) in the United Kingdom discovered that inadequate preoperative airway assessment was a major factor in airway-related complications, many of which resulted in hypoxic brain injury or death . So improved prediction algorithms could greatly minimise this burden.

The Modified mallampati Test (MMT) is a popular bedside tool for difficult airway assessment since it is simple to perform, non-invasive, and inexpensive

Despite its broad use, Modified mallampati predictive value has remained variable.  Several factors influence its accuracy, including the patient’s participation, tongue protrusion, position of the patient and phonation. However, no standardized approach exists, and the effect of these variances on predicting accuracy has not been well investigated .

Samsoon and Young updated the original Mallampati test from three to four classes .Modified mallampati Test is often conducted in sitting with head in neutral position and instructing the patient to open their mouth and protrude their tongue without phonation.

When phonated ("say ah"), it improves the mallampati score as it flattens the tongue , contracts the levator veli palatine muscle and pulls the soft palate upward and backwards. This anatomical relationship explains the correlation and laryngoscopic view on phonation . Hence here phonation is added as a parameter in the test to know its efficacy on mallampati examination.

The Cormack- Lehane (CL) grading and Mallampati classification are two widely used methods for evaluating airways and predicting difficult intubations. However, they have different functions and are carried out at various times that is one is a preoperative test while other is an intraoperative observation after induction. However their correlation is

CL Grade I–II (easy intubation) frequently correlates with Mallampati I–II. CL Grade III–IV (difficult intubation) is more often correlated with Mallampati III–IV

This study aims to find the diagnostic accuracy of Modified mallampati Test with and without phonation in upright position with Cormack- Lehane Grade III/IV  in predicting difficult laryngoscopy and intubation in adult surgical patients.

As there is limited data available in the literature regarding  the effect of phonation on modified mallampati test, the outcome of our study may lead to standardizing the way mallampati test is performed.