Difficult Endotracheal Intubation Research Articles

STUDY OF THE FACTORS AFFECTING DIFFICULT ENDOTRACHEAL INTUBATION WHO PRESENTED TO EMERGENCY DEPARTMENT IN RAMKRISHNA CARE HOSPITAL, RAIPUR, CHHATTISGARH

Background: A thorough but brief airway assessment is important and challenging for patients requiring advanced airway assessment. The study aimed to provide knowledge about the factors leading to difficult endotracheal intubation, reduce the number of attempts which will lead to more successful intubation and improve the overall quality of the procedure. Material Methods: A total of 293 patients were selected based on consecutive sampling methods. After ethical committee clearance data was collected using a data collection form. Age, gender, obesity,pre-existing medical conditions, and facial malformations were recorded for each participant. Airway assessment tests such as mouth opening, thyromental distance, hyomental distance, short neck, and Mallampati classes were conducted by investigators. Inclusion criteria were based on 1. The patient who is alive 2. The patient who needs advanced airway management The exclusion criteria were 1. The patient presented in the emergency department with ventilator support 2. Patient who didnt give consent 3. Patients below 14 years of age(pediatric age group) Data was initially entered into an Excel data sheet and then exported to SPSS Statistics version 22 for analysis. Results:From July 2022 to Aug 2023, a total of 293 patients were included in the study. Of these, 170 were male and 123 were female. Under 65 years of age 40 (43.5%) had difficult intubation whereas above 65 years 52(56.5%) had difficult intubation. 134 patients were obese resulting in difficult intubation. Female patients, those suffering from systemic diseases and facial malformation or fracture were found to be more difficult to intubate. We recognized that Mallampati classes ≥3, mouth opening < 4cm, short thyromental distance, and hyomental distance, were also associated with difficult intubation. Multiple logistic regression analysis of the related factors determined that the odds ratio was highest for mouth opening <4 cm (OR = 3.613) and Thyromental distance <6cm (OR = 3.157) Conclusion: Factors affecting difficult intubation were constructed from the patients demographic characteristics and clinical examination. This may help in discriminating against difficult intubation.This will also help in the overall success rate of first attempts of endotracheal intubation in the emergency department.

Ultrasound-Guided Airway Evaluation: Is It a Game Changer for Predicting Difficult Endotracheal Intubation?

Airway ultrasound has recently promised to be a valuable addition to preoperative airway assessment tools. This study was undertaken to determine the efficacy of ultrasound-guided measurement of soft tissue thickness (STT) at various levels of the anterior neck in predicting difficult airways in an eastern Indian population. The primary objective was to find out the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of anterior neck soft tissue thickness at the level of the hyoid (STT-Hyoid) and vocal cords (STT-VC), distance from the skin to the epiglottis midway (DSEM), and the ratio of the depth of the pre-epiglottic space (Pre-E) to the distance from the epiglottis to the mid-point of the vocal cords (E-VC). The secondary objective was to develop a scoring system using these parameters. One hundred eighty-eight patients aged 18-65 years who received general anesthesia and endotracheal intubation for surgery were included in the study. Anterior neck soft tissue thickness measurements were done preoperatively using ultrasound. The actual difficulty of the airway was graded by the anesthesiologist while performing endotracheal intubation using the intubation difficulty scale (IDS). The incidence of a difficult airway (IDS > 5) was 9.04%.The STT-Hyoid and STT-VC had a moderate correlation with IDS. The DSEM and Pre-E/E-VC ratios had a weak correlation with IDS. For difficult airway prediction, the cutoff points of STT-Hyoid and STT-VC were 7.95 mm and 24.25 mm, respectively. The combined cutoff measurements of STT-Hyoid and STT-VC (29.95 mm) were better predictors of difficult airway. Preoperative airway ultrasound examination measuring the soft tissue thickness at the hyoid and vocal cord levels is an effective modality in predicting a difficult airway. However, further studies are needed to validate this finding in populations of varied ethnicityand demographic distribution.

Incidence and Predictors of Difficult Intubation in Patients Undergoing Thyroid Surgery

Introduction: Thyroid enlargement is considered a risk factor for challenging direct laryngoscopy and intubation. Airway management in patients with thyroid swelling presents unique challenges, requiring thorough preparation for potential difficult airways. Although airway management in the overall population has been thoroughly researched, there is a scarcity of literature specifically addressing airway management in individuals who have thyroid enlargement. Aim: To evaluate the incidence of difficult intubation in patients undergoing thyroid surgery, utilising the Intubation Difficulty Score (IDS). Materials and Methods: This cross-sectional observational study was conducted among 258 patients in the Department of Anaesthesiology, Government TD Medical College, Alappuzha, Kerala, India. Various parameters including Modified Mallampati score, neck circumference, Body Mass Index (BMI), inter-incisor distance, retrognathia, neck extension, thyromental distance, tracheal deviation, and tracheal compression were assessed for all patients with thyroid swelling. The incidence of difficult endotracheal intubation was analysed using the IDS and the time taken for successful intubation was recorded. Data were presented as mean±standard deviation (SD), frequencies, and percentages. The association between variables was analysed using the Chi-square test. Results: Thyroid disorders were more common in females 220 (85.3%) than in males 38 (14.7%). The variables such as BMI, Mallampati score, thyromental distance, inter-incisor distance, and neck mobility were not found to be associated with difficult intubation. However, increased neck circumference (>43 cm) was statistically significant (p-value=0.007) in relation to difficult intubation. According to IDS, 94.2% of patients had easy intubation, while 5.8% experienced difficult intubation. In terms of intubation times, 72.5% of patients were intubated within 10-15 seconds, 24.4% within 16-20 seconds, and 3.1% took longer than 20 seconds. Conclusion: Thyroid surgery itself is not an independent predictive factor for difficult intubation. Among the predictive factors in the study population, a neck circumference greater than 43 cm was found to be associated with difficult endotracheal intubation during thyroid surgery

Prediction of difficult laryngoscopy and/or intubation among morbidly obese patients: Upper lip bite test versus modified Mallampati classification.

We aim to compare the upper lip bite test with the modified Mallampati test as predictors of difficult laryngoscopy and/or difficult intubation among morbidly obese patients. A total of 500 morbidly obese patients (body mass index > 40 kg/m2) undergoing general anaesthesia with tracheal intubation are included in this prospective single-blinded observational clinical study. The preoperative airway assessment is obtained by the modified Mallampati test and upper lip bite test. The difficulty of laryngoscopy is assessed by an experienced anaesthetist in patients adequately anaesthetised and fully relaxed. The view is classified according to Cormack and Lehane's classification. Modified Mallampati test III or IV and upper lip bite test III are considered positive tests. Difficult laryngoscopy is defined as Cormack and Lehane's classification III and IV, whereas difficult endotracheal intubation is defined as an intubation difficulty scale ⩾ 5. The incidences of Cormack and Lehane's classification III and IV and intubation difficulty scale ⩾ 5 are 9.4% and 11.8% respectively. The specificity, positive predictive value and accuracy are higher with the upper lip bite test. The combination of the upper lip bite test and the modified Mallampati test improved these measures. The likelihood ratio + was significantly higher for the upper lip bite test (6.35 and 9.47) than for the modified Mallampati test (3.21 and 3.16). The upper lip bite test is a test with high sensitivity, specificity, negative predictive value and accuracy making it a favourable test for identifying easy and difficult intubations and laryngoscopies in morbidly obese patients.

Observation of the validity of the upper lip bite test in predicting difficult intubation

The upper lip bite test (ULBT) is considered an effective method for predicting difficult airways, but data on the ULBT for predicting difficult tracheal intubation are lacking. This study aimed to examine the clinical utility of the ULBT in predicting difficult endotracheal intubation. We conducted an observational case-cohort study of adult patients undergoing elective surgery and requiring endotracheal intubation for general anesthesia. Difficult airway assessment was performed on the recruited patients before the operation, including the ULBT, mouth opening, thyromental distance, modified Mallampati test, and body mass index. The primary outcome was the incidence of difficult tracheal intubation. The receiver operating characteristic curve analysis was used to compare the performance of variables in predicting difficult tracheal intubation. We successfully recruited 2522 patients for analysis and observed 64 patients with difficult tracheal intubation. When predicting difficult tracheal intubation, grade 2 ULBT had a sensitivity of 0.75 and a specificity of 0.54, and grade 3 had a sensitivity of 0.28 and a specificity of 0.75. Compared with mouth opening, the area under the receiver operating characteristic curve of the ULBT was lower in predicting difficult tracheal intubation (0.69 [95% confidence interval: 0.67–0.71] vs. 0.84 [95% confidence interval: 0.82–0.87], P < 0.05).Clinical Trials Registry: ChiCTR-ROC-16009050, principal investigator: Weidong Yao.

Developing a magnetic POCUS-guided bronchoscope for patients with suspected difficult endotracheal intubation in a general tertiary hospital: protocol for a randomised controlled study

IntroductionEndotracheal intubation (ETI) is a crucial but risky procedure, especially among patients suspected of difficult endotracheal intubation (DTI). Bronchoscope, as an improved technique commonly used in DTI, might encounter visualisation...

Difficult airway management and low Bispectral Index (BIS) in a patient with left Bochdalek congenital diaphragmatic hernia (CDH)

BackgroundBochdalek congenital diaphragmatic hernia (CDH) is a developmental defect in the posterolateral diaphragm, allowing herniation of abdominal contents into the thorax causing mechanical compression of the developing lung parenchyma and lung hypoplasia. We describe a case of an adult patient with a Bochdalek hernia who underwent minimally invasive right thoracotomy Perceval bioprosthetic aortic valve replacement (AVR) requiring one-lung ventilation (OLV) on the side of the hernia. This is a complex and challenging case that brings up numerous thought-provoking anesthetic implications. To the best of our knowledge, a Pubmed search did not reveal any publication to date of difficult airway management in an adult patient with CDH.Case presentationThe first major problem encountered was patient’s crus habitus anatomical condition (exceedingly ventrally displaced trachea) Mallampati Class IV and Cormack-Lehane grade IV extremely difficult endotracheal intubation. Neither glottis nor epiglottis was visible on laryngoscopy; resulting in failed placement of the double-lumen endobronchial tube (DLT) following numerous attempts. The DLT was eventually placed via GlideScope videolaryngoscopy. Whereas the endobroncheal right lung block for left OLV was successfully placed using fiberopticscopy. The crus habitus encroached on OLV tidal volume by the cranially displaced ascending colon and left kidney. Anesthesia was maintained with remifentanil /sevoflurane; adjusted to maintain bispectral index (BIS) at 40–60. Digitally recorded BIS was 38–62 except when BIS precipitously declined to 14–38 (SR, suppression ratio < 10) for 25 min after termination of the cardiopulmonary bypass.ConclusionsWe report a case essentially dealing with an anatomically distorted difficult airway in a patient with left Bochdalek CDH undergoing a complex AVR. We describe anesthetic difficulties and unforeseen issues encountered; such as an extremely difficult DLT placement.

Prevalence of Obstructive Sleep Apnea in Patients with Difficult Intubation: Looking for Evidence?

BACKGROUND: The link between obstructive sleep apnea and difficult intubation needs to be fully investigated and made clear. If a compromised airway can be anticipated and managed; it can lessen the likelihood of adverse consequences. AIM: The aim of this study was to investigate the incidence, severity, and possible association of obstructive sleep apnea in individuals with unexpected difficult endotracheal intubation and their associated clinical and polysomnographic findings. METHODS: Thirty patients referred for examination after difficult endotracheal intubation were enrolled in the study group, while 30 cases from the sleep laboratory unit database with a history of surgical intervention without difficult intubation were randomly selected for the control group. Documentation was obtained for the office clinical examination and fiber-optic nasopharyngolaryngoscopy assessment by Muller maneuver. The inspected upper airway was graded clinically using the Modified Mallampati technique. A comprehensive polysomnographic assessment was done overnight. The available data from the anesthetic record, as well as those derived from clinical and polysomnographic examination, such as age, sex, Body mass index, M Mallampati score, clinical positive findings, Cormack and Lehane grade, Apnea-Hypopnea Index (AHI), desaturation index, and average O2%, were statistically analyzed. RESULTS: The mean ± SD of the AHI of the study group was (29.7 ± 16.1) while in the control group, it was (13.1 ± 9.9), and the difference was of statistical significance (p &lt; 0.001). The grading of the severity of obstructive sleep apnea (OSA) was significantly different between both groups, with 53.3% of the studied cases having severe OSA and the rest having moderate (26.7%) or mild OSA (13.3%). The desaturation index was significantly higher in the study group (28.9 ± 17.4) than the control group (10.2 ± 7.4), while the average O2% saturation was significantly lower among cases (91.8 ± 6.2). The mean modified Mallampati score was significantly higher among cases with grade III-CL, and the significance was also noticed in class IV. CONCLUSION: OSA is a major risk factor for difficult airway management and OSA patients are more likely to have difficult intubations. Patients who underwent a difficult intubation had a higher incidence and severity of OSA compared to the control group. OSA severity and higher modified Mallampati scores were independently related.

Validation of Modified Mallampati Test with Addition of Thyromental Distance and Sternomental Distance to Predict Difficult Endotracheal Intubation in Adults Presenting in Surgical Emergency

Objective: To validate modified mallampati test with addition of thyromental distance and sternomental distance in prediction of difficult endotracheal intubation in adults presenting in surgical emergency. Study Deign: Prospective, single-blinded observational study Place and duration: Department of Anesthesia and intensive care Nishtar Hospital, Multan from August 2021 to January 2022 in one year duration. Methodology: A total of 120 patients were included in the study. Difficult intubation was predicted by measuring modified mallampati test following thyromental distance and sternomental distance. Validation of mallampati test and combining predictors was assessed by measuring sensitivity, specificity, positive &amp; negative predictive value. Contingency table 2x2was designed. Results: The sensitivity and specificity of this procedure was 62.5% and 80.0%, respectively. Validity of combining all parameters to predict the difficult in endotracheal intubation was shown in table IV. The sensitivity and specificity of this procedure was 25.0% and 27.0%, respectively. Practical Implication: Endotracheal intubation is a common pre-operative complication having potential to lead poor post operative results. This study will help the anesthesiologists to overcome the problem of intubation and reduce the incidence of post operative complications in routine practice. Conclusion: Specificity of modified mallampati is too high, validity of combine parameters modified mallampati, sternomental distance and thyromental distance is very high when compared with mallampati test alone. All three parameters MMT, SMD and TMD can be used collectively for assessment of difficult airway in adult patients planned for surgery under general anesthesia. Keywords: Validity, anaesthesia, modified Mallampati test, endotracheal intubation, thyromental distance, sternomental distance

Analysis of various airway evaluation tests to prognosticate difficult endotracheal intubation

Background: Unanticipated difficult intubation or failure of intubation is a major source for anesthesia associated deaths. Hence pre-anesthetic checkup should include a detailed airway evaluation to foresee difficult endotracheal intubation. Some easy bedside tests to predict difficult airway include modified Mallampati test (MMT), ratio of height to thyromental distance (RHTMD), and upper lip bite test (ULBT). Actual difficulty of airway can be estimated using Cormack Lehane (CL) grading while performing laryngoscopy. Combination of two or more bedside clinical tests is used to identify difficult airway and act accordingly. Aims and Objectives: We aimed at identifying those airway assessment tests which best predicted difficult airway. The objectives were to determine the agreement between MMT, RHTMD, ULBT with CL grading, and also the agreement between MMT and ULBT, MMT and RHTMD. Materials and Methods: This observational research was done in 88 individuals between 18 and 75 years planned for elective procedures requiring endotracheal intubation as a part of general anesthesia. The clinical assessment tests such as ULBT, RHTMD, and MMT were done on eligible participants during pre-anesthetic check-up. In the operation theater, patient was prepared, premedicated, and induced. CL grading was used to assess the laryngoscopic view. We tried to determine the agreement between MMT, ULBT and RHTMD with CL grading. We also tried to determine the agreement between MMT and ULBT., MMT and RHTMD. Results: MMT showed moderate, RHTMD showed slight, and ULBT showed no agreement with CL grading. MMT showed highest sensitivity and RHTMD showed highest specificity. No agreement was found for ULBT and RHTMD with MMT. Conclusion: MMT and RHTMD can be used in predicting difficult airway access; out of which MMT is better than RHTMD. ULBT is not an ideal test to identify difficult endotracheal intubation. Laryngoscopic view becomes difficult with increase in weight and age.

AIRWAY MANAGEMENT GUIDELINES IN OBSTETRICS.

Anatomic and physiologic changes during pregnancy make it more difficult to establish a safe airway in pregnant women in case of the need for surgery under general anesthesia than in the non-obstetric population. The inability to ventilate and oxygenate is one of the most common causes of morbidity and mortality associated with general anesthesia for cesarean section. The aim of this paper is to present and analyze modern guidelines and algorithms for the management of difficult airway in obstetrics as an important segment of anesthesiology practice. Modern difficult airway management guidelines for pregnant women describe the procedure of difficult facemask ventilation, difficult airway management by using supraglottic devices, difficult endotracheal intubation, and emergency cricothyrotomy or tracheotomy in a situation where oxygenation and ventilation are impossible. Algorithms describe the procedures and equipment for each variant of difficult airway and decision-making strategies in situations when neither airway nor adequate oxygenation can be provided. Croatian anesthesiologists in most obstetric departments have appropriate equipment, as well as necessary experience in difficult airway management for pregnant women, and modern algorithms from the most developed countries can be adopted and accommodated to our daily practice, as well as incorporated into the training curricula of residents.

Prediction of difficult endotracheal intubation by different bedside tests: An observational study

Prediction of difficult endotracheal intubation by different bedside tests: An observational study

Application of difficult endotracheal intubation under fluoroscopy in otorhinolaryngology head and neck surgery.

Thyroid cancer, laryngeal cancer and retrosternal goiter are common diseases of head and neck, which often causes difficulty breathing and dyspnea. However, it is usually hard to use conventional methods to deal with this problem. The purpose of this study was to evaluate the safety and effectiveness of an interventional technique for difficult endotracheal intubation(DEI) caused by head and neck diseases. We retrospectively analyzed the clinical data of 35 patients who underwent an interventional technique for difficult endotracheal intubation and evaluated the efficacy of this approach and observe postoperative pulse oxygen saturation (SpO2), Hugh-Jones grade, and complications. The procedures were successfully completed in all patients who underwent DEI. The technical and clinical success rate of the procedures was 100%. The average procedure duration was 3.2 ± 1.1min (range 1-5min). The patients' postoperative SpO2 and Hugh-Jones grade improved, and dyspnea symptoms resolved. There were no serious EI-related complications. Interventional EI under fluoroscopy is a safe, simple, and fast method for accurate intubation and an effective method for DEI; furthermore, it allows for subsequent clinical treatment.

Assessment of predictors for difficult intubation and laryngoscopy in adult elective surgical patients at Tikur Anbessa Specialized Hospital, Ethiopia: A cross-sectional study

BackgroundGeneral anesthesia is not without morbidity. One of the well-known life-threatening events associated with general anesthesia is difficult airway which can happen during induction of anesthesia while attempting to insert the endotracheal tube with the aid of a laryngoscope. Difficult intubation, inadequate ventilation, and esophageal intubation are the principal causes of death or brain damage related to airway manipulation. ObjectiveThe main objective of this study was to assess the magnitude and predictors for difficult laryngoscopy and intubation among surgical patients who underwent elective surgery under general anesthesia with endotracheal intubation at Tikur Anbessa Specialized Hospital from February 1 to March 30, 2019. Materials &methodAn institutional based cross sectional study was conducted from February 1 to March 30, 2019 on patients who underwent elective surgery under general anesthesia with endotracheal intubation. Data on socio-demographic characteristics, preanesthetic airway assessment and laryngoscopic view were collected. Data were analyzed by SPSS Version 20.0. Chi- square test, binary logistic regression and multivariate analysis were performed. Tables and texts were used to present data. A p value less than 0.05 was considered as statistically significant. ResultsThe magnitude of difficult laryngoscopy, difficult intubation, and failed intubation were 12.2%, 6.1%, and 0.67%, respectively. Upper Lip Bite Test (ULBT) had a higher sensitivity (90.2%) and negative predictive value of 85.3%. Mallampati had a sensitivity of 45.8% and negative predictive value of 86% in predicting difficult laryngoscopy. Mallampati grade, thyromental distance and ratio of height to thyromental distance (HRTMD) have also showed greater sensitivity (69.6%, 58.3% and 47.8%, respectively) when compared to other tests in predicting difficult intubation. Mallampati class, upper lip bite test (ULBT) and inter-incisor distance (IID) are independent predictors for difficult laryngoscopy (p < 0.05). Furthermore, Mallampati class, Thyromental distance and ratio of height to thyromental distance (HRTMD) are identified as independent predictors of difficult intubation (p < 0.001). Conclusionand recommendation: Mallampati class, Thyromental distance and Ratio of height to Thyromental distance (HRTMD) can predict the probability of difficult endotracheal intubation in adult patients. Whereas, Mallampati class and upper lip bite test (ULBT) predicts higher probability for difficult laryngoscopy.

Anesthetic considerations for microlaryngeal surgery

Introduction: Microlaryngeal surgery encompasses a wide range of laryngeal procedures. Patients presenting for microlaryngeal surgery frequently have a difficult airway. The chosen approach to this airway depends on the pathology and the patient’s symptoms. The Aim of the study is to determine the risk factors and anesthetic problems during microlaryngeal surgery. Materials and Methods: A prospective cohort study including 100 patients undergoing microlaryngeal surgery in the Department of Otorhinolaryngology at the University Hospital „Queen Giovanna“ – ISUL, Sofia, in the period 2020–2021; Medical University-Sofia. Preoperative examination of the larynx is performed in all patients by Storz 8402 ZX fiber optic laryngoscope with video capability. Results and discussion: In 69% of the patients the tumor mass causing obstruction is localized in the area of the larynx, and in 31% of them the tumor mass is localized in the area of the hypopharynx. From the patients with tumor mass causing laryngeal obstruction 42% are with 1st degree of obstruction, 29% are with 2nd degree, 27% are with 3rd degree and 2% are with respiratory failure at rest. Twenty six percent (26%) of the patients had pulse rate&lt;45 beats per minute during putting on the tube of Kleinsasser. This is very dangerous reflex reaction of the heart, which we believe is caused by parasympathetic nervous system. The rate of difficult endotracheal intubation among patients presenting for microlaryngeal surgery is higher than among the general surgical patient population. Difficulties during endotracheal intubation in our study are due to higher percent of laryngeal obstruction and pharyngeal restriction because of the intraoral masses. Conclusion: Anesthesia for microlaryngeal surgery has always been demanding, as often pathology interferes with the anesthesiologist’s field of work.

Comparison of Upper Lip Bite Test with Modified Mallampati Score in Predicting Difficult Intubation

Background and Aims: Identifying a patient with a difficult airway is important in planning anaesthetic management so that endotracheal intubation can be achieved safely. This study aims to compare modified Mallampati score with Upper Lip Bite Test to predict difficult intubation using intubation difficulty scale. Materials and methods: A prospective study was carried on 104 patients, both sexes aged between 18 to 60 years scheduled for elective surgeries under general anaesthesia fulfilling inclusion and exclusion criteria. Patient airway was evaluated by MMT and ULBT preoperatively. Predictors of difficult endotracheal intubation were assigned to MMT class III and IV, ULBT class III. After premedication and induction laryngoscopy was performed. After successful intubation Intubation difficulty score was noted down based on the sum of seven assessing parameters. A score &gt;5 was considered difficult intubation. Results: The incidence of difficult intubation in the study was 10.6% (i.e. 11 out of 104 patients). In this study ULBT had a higher sensitivity (90.9% v/s 18.20%), specificity (95.7% v/s 75.3%) PPV (71.4% v/s 8%) and NPV (98.9% v/s 88.6%) than that of MMT Conclusion: Upper lip bite test is better at predicting difficult intubation with higher accuracy when compared to Modified Mallampati test. Both the tests are good predictors of easy intubation. Keywords: Upper Lip Bite Test (ULBT), Modified Mallampati test (MMT), Intubation Difficulty scale (IDS), airway assessment. Difficult intubation prediction, Difficult airway

Difficult Endotracheal Intubation in a Neonate: A Clinical Challenge

Difficult Endotracheal Intubation in a Neonate: A Clinical Challenge

Endotracheal intubation in an adult patient of Hallermann-Streiff syndrome-Case report and review of literature.

Dear Editor, Hallermann–Streiff syndrome (HSS), a rare genetic polymalformative dysostic syndrome with only 150 reported cases, was first described in 1893 and is characterized by bird-like facies, hypoplasia of nasal bridge, mandibular hypoplasia, hypertrichosis, ocular abnormalities, severe tracheomalacia, and dwarfism.[1] Because of facial features, airway management is considered difficult in them; however, reports are scarce with only two adult patients previously reported.[1] Paucity of literature on airway management in adult HSS patients prompted us to report the present patient as when syndromes are rare, case reports guide an anesthesiologist for management. A 20-year-old female patient of HSS, American Society of Anesthesiologists grade I, 55 kg, and 154 cm height, was posted for septo-rhinoplasty because of progressive nasal deformity since birth. She had history of snoring not associated with daytime somnolescence or night awakenings. Airway examination revealed microstomia, mouth opening of 2 cm, retrognathia, hyomental distance of 21/2 fingers, large tongue, crowding of teeth, high arched palate, small nares, and modified Mallampati Grade 3 [Figures 1 and 2]. Systemic examination and biochemical profile revealed no abnormality. As patient was anxious regarding awake fiberoptic intubation (FOI), plan was to first assess Cormack and Lehane (CL) grade on laryngoscopy in spontaneously breathing patient without muscle relaxants and in case of failure of endotracheal intubation (ETI) oral FOI under anesthesia was planned (nasal FOI was not possible due to small nares). Informed consent for emergency tracheostomy was taken. In the operation theater, routine monitors were attached. Following preoxygenation with 100% oxygen for 3 min, intravenous ketamine 50 mg with glycopyrrolate 0.2 mg was injected and sevoflurane 2–8% was gradually administered in 4–6 L/min 100% O2 preserving spontaneous respiration. Oropharyngeal airway was required for effective ventilation. Under deep anesthesia, check laryngoscopy with C Mac video laryngoscope size 3 blade revealed CL grade 1. Following this, injection atracurium 0.5 mg/kg was given and a cuffed endotracheal tube 6.5 was inserted successfully at first attempt. Intraoperative analgesia was supplemented with injection fentanyl 2 mcg/kg and paracetamol. Rest of the intraoperative period was uneventful. Surgery lasted for 3 h. At the end of surgery, neuromuscular blockade was reversed with neostigmine and glycopyrrolate and trachea extubated with no adverse sequelae. Patient was observed in recovery room for 2 h and was discharged from ward after 2 days.Figure 1: Frontal view of patient showing small and deformed naresFigure 2: Lateral view of patient showing retrognathia and decreased hyomental distanceThere are only eight reported cases of anesthesia management in HSS patients with two described in adults [Table 1][23456789] of which details of two non-English PubMed reported patients were not found.[46]Table 1: Reported cases of HSS patientsIn the reported adult patients, ETI was anticipated to be difficult; thus, awake ETI was performed in one and lighted stylet via the intubating laryngeal airway was used in the other. However in both patients, ETI was easily performed.[89] In the present patient also, airway management was anticipated to be difficult because of associated facial features like microstomia, <2 cm mouth opening, retrognathia, large tongue, crowding of teeth, and high arched palate. Contrarily ETI was easily established without any manipulations or adjuncts. This could be probably due to presence of small teeth, normal BMI, and adequate mouth opening. Through this case report, we want to highlight that even though adult HSS patients are considered to have difficult ETI, previous two reports including the present one have indicated that in an adult HSS patient, ETI might not be difficult; however, mask ventilation might be challenging. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Acromioaxillo suprasternal notch index as new screening test to predict difficult laryngoscopy in pediatric population: A case series

Prediction of pediatric difficult endotracheal intubation is a challenge for anesthesiologists. Pediatric patient possess unique characteristics in relation with difficult intubation, especially their uncooperative nature which makes conventional anatomical criteria is not applicable. Acromioaxillo suprasternal notch index (AASI) is a new test that is more objective and does not require full cooperation from the patient. Twenty patients aged 1–6 years old underwent surgery under general anesthesia with endotracheal intubation were included in this case series. AASI seems positively correlated with Cormack–Lehane grade. It is a novel but useful examination to predict the difficulty of laryngoscopic visualization during tracheal intubation in children aged 1–6 years old. More samples and further study are needed to prove the correlation in this study.

Comparative Study of Upper Lip Bite Test and Modified Mallampatti Classification in Predicting Difficult Endotracheal Intubation

Objective: To compare sensitivity, specificity, positive and negative predictive values of upper lip bite test and modified mallampatti test to predict difficulty in endotracheal intubation in patients between 16 to 55 years of age. Methods: One hundred ASA1/2 patients admitted for elective surgical procedure requiring endotracheal intubation were prospectively studied to predict difficult intubation in age group 16-55 years of age after obtaining an informed consent. Preoperative Airway assessment was done with modified mallampatti test and upper lip bite test. Results: In our study, eighty four had Upper lip bite test (ULBT) class I and II and sixteen patients had class III. Of these two ofthe ULBT class Iand II and five of the ULBTclassIII had Cormack Lehane grade III . There were one hundred patients predicted to be easy for intubation by MMT (i.e. patients who had ULBT class I and II) out of whom however, we encountered difficult intubation in 6 patients. One in MMT class III also had difficult intubation. None of the patients had class IV MMT.Of the entire one hundred patients, a total of seven patients had difficult intubation, all of whom had Cormack Lehane class III on laryngoscopy. Conclusion: Upper Lip Bite Test (ULBT)is a better test at predicting difficult endotracheal intubation when compared toModified Mallampati Test (MMT). Upper lip bite test and modified mallampatti classification are good predictors of easy intubation rather than difficult intubation. Upper lip bite test should be used in combination with other airway assessment methods viz. Thyromental distance, hyomental distance, inter incisor distance to predict difficult intubation.