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Clinical
Investigation
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
Email:rajiv.khandekar@gmail.
com
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: www.ijaweb.org 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.
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.
Patel, etal.: Validity of MMT, TMD and SMD to predict difficult endotracheal intubation
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%
Patel, etal.: Validity of MMT, TMD and SMD to predict difficult endotracheal intubation
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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
studies.
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
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.
5. IttichaikultholW, ChanpradubS, AmnoundetchakornS,
variation of predictability for a difficult intubation. ArayajarernwongN, WongkumW. Modified Mallampati
test and thyromental distance as a predictor of difficult
A more appropriate determination of validity is to laryngoscopy in Thai patients. JMed Assoc Thai 2010;93:849.
6. Magalhes E, Oliveira MarquesF, Sousa Govia C, Arajo
conduct analysis using ROC and AOC parameters
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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12. SheffSR, MayMC, CarlisleSE, KalliesKJ, MathiasonMA,
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ACKNOWLEDGMENTS Opin Anaesthesiol 2013;26:4818.
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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