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THE EFFECTIVENESS OF EXTENDED MALLAMPATI TEST, HYOMENTAL DISTANCE RATIO AND NECK CIRCUMFERENCE – THYROMENTAL DISTANCE RATIO IN PREDICTING DIFFICULT INTUBATION
ABSTRACT
Laryngoscopy and intubation could become unexpectedly difficult and this is a
significant source of morbidity and mortality in anaesthetic practice. Pre-operative
airway assessment identifies those at risk of difficult laryngoscopy / intubation so as to
adopt safer alternative strategies at induction of anaesthesia. This study evaluated the
usefulness of Extended Mallampati Test (EMT), Hyomental distance ratio (HMDR) and
Neck-circumference-thyromental distance ratio (NCTMDR) in isolation and in
combinations in apparently normal patients and correlated these predictors with difficult
intubation using Intubation Difficulty Score.
Three hundred and fourteen ASA I & II adults scheduled for elective general
anaesthesia with tracheal intubation were randomly selected. During pre-operative
review, each patient’s weight (Wt), height (Ht), and neck circumference (NC) were
measured and noted. The EMT, HMDR and NC/TMDR were also assessed for each
patient and noted. EMT class ≥3, HMDR< 1.2 and NC/TMDR ≥ 5 were considered
predictive of difficult intubation. Intraoperatively, laryngoscopy was performed and the
Cormack and Lehane (CL) grading recorded for each patient. Grades 3 and 4 were
considered difficult intubation in the CL grading. The Intubation difficulty score (IDS)
was then calculated and noted. The sensitivity, specificity, positive predictive value
(PPV), negative predictive value (NPV) and false positive (FP) values for each airway
predictor in isolation and then in combinations were determined using a 2×2
contingency table.
Difficult intubation occurred in 5 out of 314 patients (1.6 %). The sensitivity,
specificity, positive predictive value (PPV), negative predictive value (NPV), false
positive and positive likelihood Ratio (PLR) for the three predictors were: EMT (50%,
99.7%, 80%, 98.7%, 1, 153.0), HMDR (4.05%, 99.1%, 60%, 77%, 2, 4.86), and
NC/TMDR (33.3%, 99.7%, 80%, 97.4%, 1, 100.7) respectively. Although their low
false positive values (1 for EMT, 2 for HMDR and 1 for NC/TMDR) and their areas
under the curves (AUC) of receiver operator characteristic curve (ROC) showed they
were all useful predictors, the EMT was the most accurate single predictor of difficult
intubation with an AUC of ROC of 0.878 (p- value 0.000). Furthermore, the Univariate
analyses also showed that though EMT, HMDR, and NC/TMDR were related to
difficult intubation, the relationship was significant only for EMT and NC/TMDR.
EMT however had the highest precision of this relationship with a kappa coefficient of
0.608 ( p-value < 0.001). The multivariate analysis odds ratios also estimated that EMT
predicted difficult intubation about 12 times better than HMDR and also about 1.5 times
better than NC/TMDR. Again, the combination of the anatomical distances (HMDR
plus NC/TMDR) was less accurate than EMT alone ( AUC of 0.797 as against 0.878
for EMT). Combining the EMT to the anatomical distances increased their accuracy
significantly at a p-value < 0.05. Both univariate analyses and Logistic regression
showed that at a p-value of < 0.05, there was no relationship between age, gender, body
mass index (BMI), neck circumference and difficult intubation.
In conclusion, EMT had the greatest predictive profile of all the three predictors
assessed singly. EMT improved the predictive values of the anatomical distances
(HMDR and NC/TMDR) in all the combinations. There was no relationship between
age, gender, BMI, neck circumference and difficult intubation
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