Mallampati Research Articles

INCIDENCE OF VOCAL CORD PALSY IN PATIENTS UNDERGOING THYROID SURGERY FOR BENIGN CAUSES AND THE IMPACT OF AGE, GENDER, TYPE OF THYROID SURGERY, AND AN INDICATION OF SURGERY ON IT

Background 
 Thyroidectomy is common neck surgery, and recurrent laryngeal nerve (RLN) palsy is one of its devastating complications.
 Objectives 
 To know the incidence of RLN palsy in patients who underwent thyroid surgeries for benign diseases in Sulaimani city and the effect of age, gender, and indication and types of surgery on its incidence.
 Patients and Methods
 The prospective observational study included 112 patients admitted to the Otolaryngology/Head and Neck Surgery Department of Sulaimani Teaching Hospital and private hospitals in Sulaimani from May to October 2020. All cases of thyroidectomy for benign conditions were included. Patients with voice problems before surgery, thyroid malignancies, follow up for less than one month, and a history of aerodigestive tract surgery was excluded. Age, gender, and preoperative symptoms were recorded. Indications, type and technique of surgery, pre-and postoperative vocal cord status, and complications were evaluated. Mallampati scores were recorded.
 Results
 The mean ± SD (standard deviation) of patients’ ages was 43.5 ± 13.03 years, ranging from 21 to 75 years. The female to male ratio was 4.9:1, and 78 patients (69.6%) had abnormal thyroid function tests. All collected parameters from age, gender, indication and technique or type of surgery had no significant effect on postoperative vocal cord status. 
 Conclusion
 The association of age, gender, type and technique of the surgery, indication for surgery, and the diagnosis of thyroid problem with the development of RLN palsy were statistically not significant.

A Study to Evaluate Changes in Modified Mallampati Class in Patients Undergoing Spine Surgery in Prone Position.

Background: Perioperative airway changes due to anesthesia and surgery could change a normal airway at induction to a risky airway at extubation.Objectives: The objective is to evaluate primarily the degree of airway changes, as quantified by the modified Mallampati (MMP) class, after spine surgery in the prone position. Secondary to assess the time required for these changes to revert back to the preoperative state and their correlation with other demographic and surgical variables.Methods: The present prospective observational study was conducted in a tertiary care hospital after ethical approval and trial registration. Fifty ASA I and II patients aged 18-65 years of both sex and undergoing spine surgery in prone positions were included. Supine MMP grade was observed preoperatively and at one, two, four, 24, and 48 hours postoperatively.Statistical analysis: IBM SPSS version 22 (IBM Corp, Armonk, NY) was used.Mean values were compared using paired t-tests and medians by the Wilcoxon test. The Spearman correlation was used to assess a relationship. The time for recovery was analyzed by Kaplan-Meir analysis.Results: An increase in MMP grade was observed at one hour postoperatively in 46 (92%) patients. Changes reverted back in 45 (98%) patients by 24 hours postoperatively. A weak positive correlation with age, weight, body mass index, duration of surgery, perioperative drop in hemoglobin, and a moderate positive correlation with fluid administered and estimated blood loss was recorded.Conclusions: An increase in postoperative MMP occurs in the majority of patients undergoing prone position spine surgery which may persist up to 48 hours. So, more vigilance and caution are warranted should reintubation be needed postoperatively.

A CASE OF INTERMITTENT HEMOPTYSIS: THE SPECTRUM OF ANTIPHOSPHOLIPID ANTIBODY SYNDROME

TYPE: Late Breaking Case Report TOPIC: Pulmonary Manifestations of Systemic Disease INTRODUCTION: A 46 year old WM presented with several years of intermittent hemoptysis. Symptoms resolve spontaneously, improve with diuresis or required antibiotics/steroids. Evaluation for infection was negative and was maintained on daily prednisone with benefit. Malaise, hypoxemia, edema with hemoptysis but no other associated symptoms. CASE PRESENTATION: Past medical history includes CVA at age 24 related to antiphospholipid antibody syndrome and treated with anticoagulation. No other organ involvement reported. Medical history: CKD, HTN, non-ischemic cardiomyopathy. Remote 15PY tobacco history, no other exposures. On exam, room air O2 saturation 92%, desaturation to 70s with exertion. Oropharynx class III Mallampati score, lungs clear, CV RRR, no murmurs, gallops, extremities with lower extremity edema, no clubbing, rashes, ecchymosis, petechiae. Evaluation: negative ANA, DS-DNA, ENA, ANCA, anti-GBM, anti-CCP Ab. Normal immunoglobulins, complements and positive lupus anticoagulant. Chemistries: elevated creatinine, WBC 13.1, Hemoglobin 10.5, platelets 89. BNP 659, normal urinalysis. PFTs: restriction and reduced DLCO. Cardiac echo: moderately dilated LV, LVEF 40%, normal right ventricular size and function. CT chest showed diffuse bilateral pulmonary ground glass opacities. DISCUSSION: Clinical course included empiric antibiotics, bronchoscopy, heart failure management, high-dose steroids, and cyclophosphamide initiation for diffuse alveolar hemorrhage. He had clinical improvement but required readmission with progressive pulmonary symptoms, acute renal failure, and an acute ischemic stroke despite adequate anticoagulation. This met criteria for Catastrophic Antiphospholipid Antibody Syndrome. He was treated with plasma exchange, steroids/cyclophosphamide and rituximab. CONCLUSIONS: This case represents the spectrum of disorders seen in antiphospholipid antibody syndrome. Antiphospholipid antibody syndrome can have a broad range of presentation in the lungs. DISCLOSURE: Nothing to declare. KEYWORD: ANTIPHOSPHOLIPID ANTIBODY SYNDROME

0823 ACDF - A hidden etiology of OSA

Abstract Introduction OSA is characterized by recurrent episodes of upper airway collapse and obstruction during sleep, leading to oxygen desaturations. Risk factors include obesity, age, sex, family history, craniofacial abnormalities, stroke, diabetes, polycystic ovarian syndrome. This case illustrates symptomatic and clinically proven worsening of OSA after anterior cervical discectomy and fusion (ACDF), which can lead to narrowing of the airspace and dysfunction of the pharyngeal plexus leading to upper airway collapse. Report of Cases: A 49-year-old female with cervical myelopathy was evaluated in the sleep clinic for snoring, witnessed apnea, and daytime somnolence. Her Epworth score was 11, and Mallampati score was 4, suggestive of underlying sleep-disordered breathing (SDB). A home diagnostic sleep test revealed mild OSA with AHI of 6.8/hr and was started on an Auto Continuous Positive Airway Pressure (APAP) device. She then reported worsening of her cervical pain leading to decreased use of APAP and total sleep time and underwent ACDF approximately 6 months after her diagnosis of OSA was made. Post-surgery she reported mild dysphagia, frequent nighttime awakening due to a choking sensation, and an increase in snoring. Following hospital discharge, the patient was re-evaluated in the sleep clinic for these complaints. Upon review, her BMI had decreased to 33.99 kg/m2, from 37.35 kg/m2, and the only medication change was the addition of hydrocodone-acetaminophen 5-325, 1-2 times daily as needed for pain. A repeat diagnostic home sleep study showed progression of OSA to moderate severity with an AHI of 24.5/hr, with no evidence of central sleep apnea or hypoventilation. Therefore, it was unlikely that the worsening of AHI was due to opioids. Thus, it was concluded that ACDF most likely led to the worsening of OSA. Conclusion Although there is no strong association in medical or sleep literature, this case demonstrates a strong association between ACDF and OSA. This highlights the importance of a timely diagnosis of new-onset or reassessment for worsening OSA in patients post-ACDF to improve sleep quality and prevent morbidity. Support (If Any)

0846 Severe OSA in a 17yr old patient with Prader Willi Syndrome and poorly controlled Diabetes Mellitus

Abstract Introduction Prader Willi Syndrome (PWS), while rare, is the most common genetic cause of obesity. It is caused by a functional loss of paternally expressed genes from chromosomal region 15q11-13. PWS is characterized by short stature, neurodevelopmental delay, obsessive-compulsive behaviors, hypothalamic dysfunction, and hyperphagia, associated with an aberrant satiety response and elevated levels of ghrelin. Excessive daytime sleepiness (EDS) and sleep-disordered breathing (SDB), including obstructive sleep apnea (OSA) and central sleep apnea, are common. Report of Cases: A 17-year-old male, with PWS, morbid obesity, autism, and diabetes mellitus (DM) type-2 was referred for evaluation of snoring and EDS (Epworth Sleepiness Score 16). He had recently been admitted with diabetic ketoacidosis associated with binge eating. He had no prior sleep testing. He denied sleep paralysis, hypnagogic/hypnopompic hallucinations, and cataplexy. He had a body mass index of 54 kg/m2 with short stature (1.6m). On exam, he had a Mallampati score of 4 and 1+ tonsils. A recent echocardiogram was normal. Polysomnography showed sleep latency of 10 mins, apnea-hypopnea index (AHI) of 148/hr, nadir oxygen saturation of 73%, with 45% of total sleep time < 90%. Hypoventilation was not present. He was prescribed auto-titrating positive airway pressure (PAP) therapy. His mother was instructed to start locking access to food again. He was treated with insulin and metformin, with a plan to start on a glucagon-like peptide-1 (GLP-1) agonist. He had been on growth hormone (GH) previously, but in the context of his other morbidities, it was not reinitiated. Conclusion It is critical to screen and monitor patients with PWS for OSA, as SDB occurs in almost 70%. While PAP therapy may improve OSA, there is often residual EDS (likely due to underlying hypothalamic dysfunction), and alerting agents may be needed. GH can be considered for short stature but is contraindicated in patients with morbid obesity, untreated severe OSA, and uncontrolled diabetes. Management of diabetes, obesity, and hyperphagia in patients with PWS is challenging. Supervision and strict limitation of food intake using physical barriers are important. While data are limited, GLP-1 agonists may provide potential benefits for weight, glycemic, and appetite control in patients with PWS. Support (If Any)

0567 When Loud Sleep Aids a Silent Killer: A Prevalence Study on Obstructive Sleep Apnoea in Type-2 Diabetics from a Tertiary Care Hospital in Western India

Abstract Introduction Type-2 diabetes mellitus is a highly prevalent multisystemic disorder having bidirectional association with Obstructive sleep apnoea. These disorders, when present as co-morbidities, can lead to life-threatening cardiovascular complications. The current prevalence of Obstructive sleep apnoea in Type-2 diabetics is largely unknown, especially in developing nations like India. This study was aimed at determining its prevalence and other risk factors in Type-2 diabetics visiting a tertiary-care hospital in Western India. Methods Adult patients with Type 2 diabetes mellitus visiting the Departments of Pulmonary medicine and Non-communicable diseases on an out-patient basis at a tertiary-care hospital were recruited for the study. Those with unstable medical illnesses or other forms of diabetes were excluded. Participants were interviewed and examined based on a case-study form, including Epworth Sleepiness Scale, STOP-BANG and OSA-50 questionnaires, followed by a Home Sleep Apnoea Test. Apnoea-Hypopnoea Index(AHI) was used to evaluate for Obstructive sleep apnoea. Results A sample of 62 diabetics (median age: 61(16) years; 34 males; 28 females) was analysed. Obstructive sleep apnoea(Apnea-Hypopnea Index [AHI] ≥ 5.0/h) was diagnosed in 55 subjects(88.7%, median AHI – 20.95/h). 62.9% had moderate-to severe Obstructive sleep apnoea(OSA)(AHI ≥ 15/h), 21% had positional OSA and 48.4% had OSA syndrome(OSAS). AHI had significant positive correlation with waist circumference(rho- 0.318, p- 0.012), neck circumference(rho-0.363, p-0.004), Modified Mallampati score(rho-0.372, p-0.003) and Epworth Sleepiness Scale(rho-0.403, p-0.001). No significant association of glycaemic control, duration of Type-2 diabetes and Random Blood Sugar level with AHI was identified. Sensitivity and specificity of STOP-BANG questionnaire for diagnosing OSA was 69.1% and 71.4% and that of OSA-50 questionnaire was 94.5% and 14.3%, respectively. Conclusion Obstructive sleep apnoea(OSA) is more prevalent in adult population with Type-2 diabetes mellitus(T2DM) than in the general population. A high index of suspicion for OSA in patients with T2DM is warranted, because they may not have overt daytime sleepiness or presence of high-risk predictors. Waist and neck circumferences are better predictors of OSA syndrome than body mass index(BMI). Home Sleep Apnoea Test is a more reliable test for OSA detection compared to screening questionnaires and hence can be a useful tool for diagnosis and management planning of OSA in high-burden, low-resource settings. Support (If Any)

0843 Sexsomnia in a female patient with nightmares and obstructive sleep apnea: a case report

Abstract Introduction Sexsomnia has been described as various sleep-related abnormal sexual behaviors primarily associated with confusional arousals and more rarely linked to rapid eye movement (REM) sleep behavior disorder (RBD). Clinical descriptions are based on case reports and review series, which leads to diagnostic ambiguity, challenges with appropriate classification, and forensic and legal ramifications Report of Cases: We report a 34 year old female with a past medical history of polycystic ovarian syndrome and childhood post-traumatic stress disorder. Family history significant for parent with lifelong parasomnias. The patient was referred to Sleep Medicine with concern for snoring, sleepiness, and sleep behaviors. The patient reports sleep talking since childhood which predate trauma, traumatic themed nightmares, and ex-husband and current spouse reporting sleep-related masturbation, sexual advances described as coital-like pelvic movements which often lead to intercourse and subsequent amnesia. In addition, spouse describes bruxism and ongoing night terrors. Physical examination notable for body mass index 44 kg/m2, high arched palate, Mallampati class III, and 18 inch neck circumference. The patient underwent a polysomnagram which demonstrated fragmented sleep architecture, total arousal index up to 20.3/hr, and totalsleep time in stage N3 20%, Four awakenings fromN3, and findings of N3 partial arousal. The patient was observed in v-PSG to have periods of nocturnal lagophthalmos, finger movements, and vocalizations during NREM sleep. However, many of these observations were in the setting of respiratory events. The apnea-hypopnea index was 16.9/hr and a minimum oxygen saturation of 81% and mean saturation of 95%. A total of 3.1 minutes were spent less than or equal to 90%. TCO2 was without concern for hypoventilation. The patient was started on Auto CPAP 5-15cmH2O with resolution of snoring and some improvement to sleepiness. However, spouse reports ongoing sexsomnia in the same frequency despite treatment of obstructive sleep apnea. Conclusion This case reports a female adult with persistent sexsomnia despite early treatment of obstructive sleep apnea which highlights the possibility of co-occurring sleep disorder. The case does support current limited literature around sexsomnias having features of partial arousals from NREM sleep given the co-occuring history of night terrors, elevated N3 awakenings, and evidence of cortico-cortical dissociation. Support (If Any) None

Mallampati Score Is an Independent Predictor of Active Oxygen Therapy in Patients with COVID-19.

Mallampati score has been identified and accepted worldwide as an independent predictor of difficult intubation and obstructive sleep apnea. We aimed to determine whether Mallampati score assessed on the first patient medical assessment allowed us to stratify the risk of worsening of conditions in patients hospitalized due to COVID-19. A total of 493 consecutive patients admitted between 13 November 2021 and 2 January 2022 to the temporary hospital in Pyrzowice were included in the analysis. The clinical data, chest CT scan, and major, clinically relevant laboratory parameters were assessed by patient-treating physicians, whereas the Mallampati score was assessed on admission by investigators blinded to further treatment. The primary endpoints were necessity of active oxygen therapy (AOT) during hospitalization and 60-day all-cause mortality. Of 493 patients included in the analysis, 69 (14.0%) were in Mallampati I, 57 (11.6%) were in Mallampati II, 78 (15.8%) were in Mallampati III, and 288 (58.9%) were in Mallampati IV. There were no differences in the baseline characteristics between the groups, except the prevalence of chronic kidney disease (p = 0.046). Patients with Mallampati IV were at the highest risk of AOT during the hospitalization (33.0%) and the highest risk of death due to any cause at 60 days (35.0%), which significantly differed from other scores (p = 0.005 and p = 0.03, respectively). Mallampati IV was identified as an independent predictor of need for AOT (OR 3.089, 95% confidence interval 1.65–5.77, p < 0.001) but not of all-cause mortality at 60 days. In conclusion, Mallampati IV was identified as an independent predictor of AOT during hospitalization. Mallampati score can serve as a prehospital tool allowing to identify patients at higher need for AOT.

A Prospective Study to Correlate Difficult Intubation with Difficult Laryngeal Exposure for Microlaryngeal Surgery using Various Grading Scales of Difficult Intubation.

Adequate visualization of the vocal folds is essential for optimal phonosurgery. Pre-operative knowledge of a difficult laryngeal exposure (DLE) can alert the surgeon regarding the need for alternative measures. Our study is based on the hypothesis that a patient who has difficult intubation (DI) is likely to have DLE, thus scales anticipating DI should also anticipate DLE. Our aims were to correlate patients of actual DI on table with patients who had DLE, secondly to assess the ability of grading scales of DI to predict DLE and finally to obtain a cut-off value of neck circumference and length for predicting DLE. This is a prospective, observational study wherein four grading scales; Modified Mallampati Classification (MMC), 3-3-2, Upper lip bite test (ULBT) and Neck Mobility (NM) were used for anticipating DI and correlated with DLE during MLS. Occurrence of actual DI and DLE was correlated. Neck circumference and neck length was correlated with incidence of DLE. Out of 42 patients, 22 were anticipated to have DI (52.38%). Actual incidence of DI was 6 (14.28%) and DLE was 10 (23.80%). Correlation between actual DI and DLE was statistically significant. Of the 4 grading scales, ULBT was significant in predicting DLE. Neck circumference more than 37.5cm and neck length less than 15.3cm was significant in anticipating DLE. There is a significant correlation between DI and DLE. A positive ULBT, neck circumference more than 37.5 cms and neck length less than 15.3 cms are independently suggestive of a DLE.

Predicting difficult laryngoscopy in morbidly obese Thai patients by ultrasound measurement of distance from skin to epiglottis: a prospective observational study

BackgroundIn morbidly obese patients, airway management is challenging since the incidence of difficult intubation is three times than those with a BMI within the healthy range. Standard preoperative airway evaluation may help to predict difficult laryngoscopy. Recent studies have used ultrasonography-measured distance from skin to epiglottis and pretracheal soft tissue at the level of vocal cords, and cut-off points of 27.5 mm and 28 mm respectively have been proposed to predict difficult laryngoscopy. The purpose of this study is to evaluate ultrasonography-measured distance from skin to epiglottis for predicting difficult laryngoscopy in morbidly obese Thai patients.MethodsThis prospective observational study was approved by the Ethics Committee of the Faculty of Medicine, Prince of Songkla University. Data were collected from January 2018 to August 2020. Eighty-eight morbidly obese patients (BMI ≥ 35 kg/m2) requiring general anesthesia with endotracheal intubation for elective surgery were enrolled in the Songklanagarind Hospital. Preoperatively, anesthesiologists or nurse anesthetists who were not involved with intubation evaluated and recorded measurements (body mass index, neck circumference, inter incisor distance, sternomental distance, thyromental distance, modified Mallampati scoring, upper lip bite test, and distance from skin to epiglottis by ultrasound. The laryngoscopic view was graded on the Cormack and Lehane scale.ResultsMean BMI of the eighty-eight patients was 45.3 ± 7.6 kg/m2. The incidence of difficult laryngoscopy was 14.8%. Univariate analysis for difficult laryngoscopy indicated differences in thyromental distance, sternomental distance and the distance from skin to epiglottis by ultrasonography. The median (IQR) of thyromental distance in difficult laryngoscopy was 6.5 (6.3, 8.0) cm compared with 7.5(7.0, 8.0) cm in easy laryngoscopy (p-value 0.03). The median (IQR) of sternomental distance in difficult laryngoscopy was 16.8 (15.2, 18.0) cm compared with 16.0 (14.5, 16.0) cm in easy laryngoscopy (p-value 0.05). The mean distance from skin to epiglottis was 12.2 ± 3.3 mm Mean of distance from skin to epiglottis in difficult laryngoscopy was 12.5 ± 3.3 mm compared with 10.6 ± 2.9 mm in easy laryngoscopy (p-value 0.05). Multivariate logistic regression indicated the following factors associated with difficult laryngoscopy: age more than 43 years (A), thyromental distance more than 68 mm(B) and the distance from skin to epiglottis more than 13 mm(C). The scores to predict difficult laryngoscopy was calculated as 8A + 7B + 6C based on the data from our study. One point is given for A if age was more than 43 years old, 1 point is given for B if thyromental distance was less than 6.8 cm and 1 point is given for C if the distance from skin to epiglottis by ultrasonography was more than 13.0 cm. The maximum predicting score is 21, which indicates a probability of difficult laryngoscopy among our patients of 36.36%, odds 0.57, likelihood ratio 3.29 and area under the ROC curve of 0.77, indicative of a good predictive score.ConclusionsAge, thyromental distance and ultrasonography for the distance from skin to epiglottis can predict difficult laryngoscopy among obese Thai patients. The predictive score indicates the probability of difficult laryngoscopy.

Predicting difficult intubation in apparently normal subjects

One of the major problems faced by health care professionals is the prediction of airway difficulties in apparently healthy subjects. Failed endotracheal intubation is a well-known reason for increased morbidity of patients including brain damage or even death. This study is focused on parameters used for prior determination of airway for predicting difficult intubation in healthy Indian populations. This study was done on 500 healthy individuals. Neck parameters were measured including inter-incisal distance, neck circumference, thyro-mental distance and sterno-mental distance. Mallampati classification and mandibular protrusion test were also carried out. Statistical analysis was done using SPSS software (V.25). MC class 3 and 4 percentages were higher in males in comparison to females. Mandibular protrusion test grade A and B percentage was higher in females while class C percentage was higher in males. The comparison of baseline values of the neck parameters (inter-incisal distance, neck circumference, thyro-mental distance and sterno-mental distance) was statistically significant (&lt;0.05) in both genders. The purpose of the study is to find out the baseline values of parameters involved in assessing methods for difficult intubation in healthy Indian population.

Endoscopy-assisted transoral approach for parapharyngeal space tumors: Our experience and a systematic review of the literature.

Several approaches have been described for the excision of parapharyngeal space tumors (PPSTs). Advances in endoscopy gave a further stimulus to the use of the transoral route. We present our experience with the endoscopy-assisted transoral approach (EATA) in this regard and a review of the most recent literature about EATA for PPSTs excision. We retrospectively analyzed our experience and systematically reviewed the literature about the outcomes of this technique. Seven PPSTs were completely excised, with three of them requiring a combined transcervical approach. Only one case of postoperative wound dehiscence was registered, and the mean length of stay was 3.9 days. Final histopathological examination confirmed the results obtained with preoperative fine-needle aspiration biopsy in all cases and no recurrences were apparent after a mean follow-up of 28.1 months. Magnetic resonance imaging, the modified Mallampati score and the 8 Ts criteria are useful instruments for the choice of the most appropriate surgical approach. In light of our experience and following other published series in the literature, we believe that EATA may represent a safe and effective approach for the treatment of the majority of PPSTs.

Obesity and the Other Independent Predictors in Elective Endotracheal Tube Intubations: A Narrative Review.

Obesity is one of the challenging elements in health care. Studies have shown that as the body mass index (BMI) increases, the risk of chronic conditions tends to increase due to altered physiologic and metabolic demands. In addition to underlying physiological changes, anatomical changes can lead to common procedural challenges, such as difficult intravenous (IV) cannulation, difficult airway, and difficult intubation, which makes their preoperative and postoperative care challenging for the anesthesiologists. According to previous studies, there is no single best predictor for difficult airway or intubations and no designed protocol for choosing an intubation technique in obese patients. Some of the preoperative risk factors and techniques such as the modified Mallampati class, sternomental distance, thyromental distance, neck circumference, indirect mirror laryngoscopy, BMI, and intraoperative risk factors such as inappropriate positioning of the patient, suboptimal medication dosing, inappropriate laryngoscopy device acted as independent predictors for difficult airway and difficult intubation. Analyzing each element’s importance and making suitable decisions for the individual will reduce the complications and prepare for unplanned emergencies in the operating room. This review is convincing with previous studies that obesity itself is not an independent predictor. Instead, as a preoperative risk factor, and till date, sternomental distance and the number of intubation attempts were demonstrated as significant independent predictors for adverse events. All the other independent factors and considerations were discussed, which can help with further research.

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.

Relevance of ratio of neck circumference to thyromental distance in predicting difficult intubation

Background and Objectives: Airway assessment is the most important aspect of anaesthetic practice as a difficult intubation may be unanticipated. A study was done to know the relevance of ratio of neck circumference to thyromental distance in predicting difficult intubation in general Indian population coming for surgery. Materials and methods: 500 Patients with ASA PS I&amp; II were enrolled in the study were preoperatively assessed for airway parameters such as Modified mallampati classification, thyromental distance, sternomental distance, neck circumference to thyromental distance ratio and Wilson score. Intra-operatively all patients were classified according to Cormack and Lehane laryngoscopic view. Results: The mean age, Weight, Height and BMI of patients in our study was 34.43 years, 61.07 kg,69.2cms and 21.2 respectively. In our study we had a total of 15 difficult intubation with all of them belonging to Cormack-Lehane grade III. In our study we noted that among 15 patients with CLIII/IV only 4 had a SMD≤15.75 cm. With that we noted a sensitivity, specificity, PPV and NPV of 26.7%,75.1%,3.2% and 97.1%. Among 15 patients with CLIII/IV only 2 of them had Wilson score of more than 3.

Predicting upper airway collapse sites found in drug-induced sleep endoscopy from clinical data and snoring sounds in patients with obstructive sleep apnea: a prospective clinical study.

The primary aim was to predict upper airway collapse sites found in drug-induced sleep endoscopy (DISE) from demographic, anthropometric, clinical examination, sleep study, and snoring sound parameters in patients with obstructive sleep apnea (OSA). The secondary aim was to identify the above-mentioned parameters that are associated with complete concentric collapse of the soft palate. All patients with OSA who underwent DISE and simultaneous snoring sound recording were enrolled in this study. Demographic, anthropometric, clinical examination (viz., modified Mallampati classification and Friedman tonsil classification), and sleep study parameters were extracted from the polysomnography and DISE reports. Snoring sound parameters during DISE were calculated. One hundred and nineteen patients with OSA (79.8% men; age = 48.1 ± 12.4 years) were included. Increased body mass index was found to be associated with higher probability of oropharyngeal collapse (P < .01; odds ratio = 1.29). Patients with a high Friedman tonsil score were less likely to have tongue base collapse (P < .01; odd ratio = 0.12) and epiglottic collapse (P = .01; odds ratio = 0.20) than those with a low score. A longer duration of snoring events (P = .05; odds ratio = 2.99) was associated with a higher probability of complete concentric collapse of the soft palate. Within the current patient profile and approach, given that only a limited number of predictors were identified, it does not seem feasible to predict upper airway collapse sites found in DISE from demographic, anthropometric, clinical examination, sleep study, and snoring sound parameters in patients with OSA. Huang Z, Bosschieter PFN, Aarab G, etal. Predicting upper airway collapse sites found in drug-induced sleep endoscopy from clinical data and snoring sounds in obstructive sleep apnea patients: a prospective clinical study. J Clin Sleep Med. 2022;18(9):2119-2131.

Anatomical location of the vocal cords in relation to cervical vertebrae, a new predictor of difficult laryngoscopy: A descriptive cross sectional study

Airway management is among the challenges faced by the anaesthesiologists. There are anatomical and clinical factors, which can predict the difficult laryngoscopy. In this study, the aim was to predict the easy and difficult laryngoscopy preoperatively by assessing the anatomy of patient’s head and neck. The objective was to assess the same by using the magnetic resonance imaging films of the neck. The study included 110 adult patients with existing preoperative magnetic resonance imaging scans of neck. Preoperative anaesthetic assessment was done by using the thyromental distance, sternomental distance, body weight, mouth opening, Mallampati classification and head neck movement. The magnetic resonance imaging scans were screened for slices to visualise the vocal cords. A projection line was drawn to determinethe topography of vocal cords in relation to the cervical vertebrae. The ease of laryngoscopy by Cormack-Lehane grade was then correlated with the vertebral level of the vocal cords.The laryngoscopy was difficult in over weight patients (p&amp;#60;0.001) and with smaller thyromental distance. It was also observed that the laryngoscopy was easy (p&amp;#60;0.001), when the topographical location of vocal cords were related to C5 and hard, when they are at the level of C4 and C6 (p&amp;#60;0.001). Magnetic resonance imaging films of neck could be used to evaluate the potential difficult laryngoscopy, preoperatively. It can be used along with the existing bedside tests like determination of thyromental distance, sternomental distance and modified Mallampati classification.

Oral cavity morphology among children at risk of sleep disordered breathing.

The aim of this study was to evaluate oral cavity morphology in children at risk of sleep disordered breathing (SDB). The study included children 3-17years of age. The risk of SDB was evaluated using the paediatric sleep questionnaire (PSQ); afterwards, children at risk of SDB were enrolled in the study group. A control group was randomly established from patients with negative PSQ results. The oral cavity morphology evaluation included assessment of the oropharynx using Mallampati classification (MC), palatine tonsil size using the Pirquet scale, occlusion and the presence of a high-arched palate and lingual frenulum. A total of 131 children were evaluated, 65 in the study and 66 in the control group. The mean ages were 9.5 ± 3.0 and 9.4 ± 3.1years, respectively. The presence of higher scores on the MC, higher scores in the Pirquet scale, a crossbite, a high-arched palate and a short frenulum were significantly more frequent in the study group than the control group. The evaluation of oral morphology is an important part of paediatric examination. Enlarged palatine tonsils; higher scores on the MC; and the presence of a crossbite, short lingual frenulum and high-arched palate may suggest abnormal breathing during sleep in children.

Effectiveness of physiotherapy Intervention on trismus (lock –jaw)

Introduction:-Trismus is a condition which is not very common among general population. Therefore, most of the people are not aware regarding this. Basically medical and surgical management is provided and very few go for physiotherapy management. Case Description:-In this case study 30 year unmarried female came to physiotherapy clinic with the problem in mouth opening and pain in jaw. She went for complete assessment before intervention in which via 3 methods we measured maximum mouth opening. Intervention:-In this study we gave 4 weeks of intervention with 5 sessions/week to the patient. In all the 4 weeks intervention was same. Dry heating was given for 20 minutes followed by ultrasound and stretching exercises. Outcome measures: - In outcome measures mouth was observed and leveled with the help of Modified Mallampati score. Maximum mouth opening was measured with measuring scale, 3 finger width test and measurement via vernier caliper. All the parameters showed the significant results after the interventions.

A case of monosomy 21 presented with difficult tracheal intubation

BackgroundMonosomy 21 is a rare chromosomal abnormality. It is mainly associated with mental retardation, intellectual disability, growth retardation, microcephaly, and characteristic facial features. General anesthesia in adults with this disease has not been reported. We report difficult airway management of an adult patient with monosomy 21.Case descriptionA 30-year-old female was scheduled for laparoscopic gynecological surgery. She was diagnosed with monosomy 21 at birth and accompanied with mental retardation. Preoperative examination revealed limited mouth opening with Mallampati score of IV, but no abnormal laboratory test or chest X-P. Anesthesia was performed using general anesthesia with epidural analgesia. Although bag-mask ventilation was improved by a muscle relaxant, mouth opening was further restricted, and laryngoscope insertion was impossible. Tracheal intubation was achieved using a bronchofiberscope. The operation procedure was completed, and the patient was discharged from the hospital without any major postoperative complications.ConclusionsIn this patient, mouth opening was further reduced after induction of general anesthesia with a muscle relaxant. Preoperative evaluation and adequate preparation of airway management are important for general anesthesia in an adult patient with monosomy 21.