A New Class for Modified Mallampati Sign
- Prabhat K. Sinha, MD, PDCC,
- Sukanya Mitra, MD,
- Satinder Gombar, MDand
- Kanti K. Gombar, MD
The Mallampati sign, which is a simple, quick method to predict difficulty with tracheal intubation (1), has gained considerable popularity for airway examination during preanesthetic visits. This sign is dependent on the relative size of the tongue in relation to the pharyngeal structure, but its serious limitations must be evaluated. We report an observation we made during the preoperative airway assessment of a patient in whom we could not ascertain a Mallampati grading.
An 80-yr-old, 76-kg woman scheduled for laparoscopic cholecystectomy had a history of repeated oral surgery (five times) for carcinoma of the tongue. During a preanesthetic check-up, we found a complete absence of a tongue, uvula, mandible, and other pharyngeal structures (Figures 1 and 2). Therefore, we were unable to perform Mallampati or modified Mallampati grading (2); hence, prediction of airway difficulty could not be ascertained. Because the patient refused to undergo the operation, we cannot say with certainty whether this patient had a difficult airway.
Figure 1. Front view of patient’s face with wide opened mouth showing the absence of pharyngeal structures.
Figure 2. Side view of patient’s face.
Ezri et al. (3) described a clinical situation in which the epiglottis (tip and posterior aspect) could be visualized on mouth opening and protrusion of the tongue and proposed a Mallampati class 0 for this clinical situation. We propose another Mallampati class for cases in which a Mallampati grading cannot be ascertained because of partial or complete absence of the tongue and/or pharyngeal structures. In such an event, preoperative a clinical airway assessment using this grading system is difficult. This situation may be graded as class 5. However, further study is therefore required in relation to difficult intubation in this class.
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