Thyromental Distance Research Articles

Non-traumatic complete cervical spine dislocation with severe fixed kyphosis: successful multidisciplinary approach to a challenging case

BackgroundTo our knowledge, there is no previous report in the literature of non-traumatic neglected complete cervical spine dislocation characterized by anterior spondyloptosis of C4, extreme head drop, and irreducible cervicothoracic kyphosis.Case presentationWe report the case of a 33-year-old Caucasian man with a 17-year history of severe immune polymyositis and regular physiotherapy who presented with severe non-reducible kyphosis of the cervicothoracic junction and progressive tetraparesia for several weeks after a physiotherapy session. Radiographs, computed tomography, and magnetic resonance imaging revealed a complete dislocation at the C4–C5 level, with C4 spondyloptosis, kyphotic angulation, spinal cord compression, and severe myelopathy. Due to recent worsening of neurological symptoms, an invasive treatment strategy was indicated. The patient’s neurological status and spinal deformity greatly complicated the anesthetic and surgical management, which was planned after extensive multidisciplinary discussion and relied on close collaboration between the orthopedic surgeon and the anesthetist. Regarding anesthesia, difficult airway access was expected due to severe cervical angulation, limited mouth opening, and thyromental distance, with high risk of difficult ventilation and intubation. Patient management was further complicated by a theoretical risk of neurogenic shock, motor and sensory deterioration, instability due to position changes during surgery, and postoperative respiratory failure. Regarding surgery, a multistage approach was carefully planned. After a failed attempt at closed reduction, a three-stage surgical procedure was performed to reduce displacement and stabilize the spine, resulting in correct spinal realignment and fixation. Progressive complete neurological recovery was observed.ConclusionThis case illustrates the successful management of a critical situation based on a multidisciplinary collaboration involving radiologists, anesthesiologists, and spine surgeons.

Ultrasound-based assessment of tongue thickness for prediction of difficult laryngoscopy and intubation.

Predicting difficult airway and preparedness for the same can help prevent catastrophic situations while handling the airway. With the increasing familiarity of anaesthesiologists to the use of ultrasound machine and its easy availability and non-invasiveness, we sought to study its utility in airway assessment, by measuring the thickness of tongue, to predict difficult laryngoscopy and intubation. A total of 85 patients undergoing elective surgeries under general anaesthesia with endotracheal intubation were examined preoperatively. Tongue thickness was measured using submental ultrasonography in the median sagittal plane along with other tests of airway assessment. Cormack Lehane grade on laryngoscopy and Intubation Difficulty Scale Score was recorded. The sensitivity, specificity, positive and negative predictive value, and accuracy was calculated for tongue thickness for predicting difficult intubation. The tongue thickness in those with difficult intubation (4.83 ± 0.62) was significantly higher than those without difficult intubation (4.38 ± 0.65). The ratio of tongue thickness to thyromental distance was also significantly higher in difficult intubation group. The area under the receiver operating characteristic curve for predicting difficult laryngoscopy and intubation was higher for tongue thickness as compared to other clinical parameters. The sensitivity and specificity of tongue thickness to predict difficult laryngoscopy was 100% and 83%, respectively, and to predict difficult intubation was 72% and 59%, respectively, with an accuracy of 72%. Ultrasound based assessment of tongue thickness can be a useful predictor of difficult airway along with clinical assessment of the airway.

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.

The Diagnostic Value of Sub-mental Fat Measurement for Prediction of Difficult Laryngoscopy and Intubation: A Randomized Prospective Study

Background: Difficult airway management poses a high-risk procedure, potentially leading to patient mortality. Despite significant advancements in modern anesthesia over the years, there remains a lack of a single reliable tool for predicting difficult airways. Objectives: This study aims to examine neck fat diameter as a potential predictor of airway difficulty. Methods: Two hundred fifty patients participated in the study. Airway parameters, including Mallampati score, mandibular protrusion, upper lip bite test, thyromental distance, neck movements, and neck fat diameter, were documented. Results: Among our study population, 48 patients experienced difficult intubation. The Mann-Whitney test revealed that submental fat was significantly greater in the difficult intubation group (P-value < 0.001). Based on the best subset variable selection, submental fat, thyromental distance (model 1), and age (model 2) were selected to participate in the multivariate regression model. Each one mm increase in neck fat was associated with a 30% increase in the odds of difficult intubation (P-value < 0.001) in the univariate logistic model. After adjusting for thyromental distance, age, and gender, the odds of difficult intubation were approximately 2 times higher in patients with 1 mm more neck fat (P-value 0.007). The area under the curve of the Receiver Operating Characteristics curve and McFadden's pseudo-R squared of the multivariate model were 0.998 and 0.91, respectively. Conclusions: Neck fat diameter serves as a reliable and straightforward predictor of airway difficulty and can be used alone or in conjunction with other predictors for the prediction of difficult airway management.

Validity of Airway Ultrasound in Correlation with Cormack-Lehane Grading in Obese Patients: A Cross-Sectional Study.

Ultrasound (US) of the upper airway has the potential to be a valuable addition to traditional clinical evaluation methods. This work aimed to assess the validity of US in correlation with Cormack-Lehane grading (CLG) in obese patients. This cross-sectional work was performed on 78 patients ranging in age between 21 and 60 years, both genders with the American Society of Anesthesiologists (ASA) II-III individuals and body mass index (BMI) 30 kg/m² or more, under general anesthesia with endotracheal tube placement. Each separate finding by the US and conventional clinical airway assessment methods before anesthesia induction correlated to the CLG of the same patient after the induction of anesthesia. Grades III and IV are categorized as difficult laryngoscopy. A significant positive association existed among CLG and duration of US measures, pre-epiglottis spaces (Pre-E) ratios, to the distance between a point mid away vocal cords and epiglottis, Pre-E, ratio of hyomental distance extension/hyomental distance neutral and Mallampati; however, there was a significant negative correlation with skin to anterior commissure, hyomental distance extension, hyomental distance neutral, sternomental distance, and thyromental distance (P < 0.05). The ratio between Pre-E over the distance between the epiglottis and a point midway through the vocal cords at cut-off > 2.23 can discriminate difficult laryngoscopy with sensitivity 100% and specificity 100% and area under the curve of 1. The sonographic assessment of the upper airway aids in predicting individuals who might have challenges with airway management. A reliable indicator of a challenging laryngoscopy was the sonographic parameter ratio of Pre-E to the distance between the vocal cords' midway point and the epiglottis.

The Importance of Evaluation of Neck Circumference to Thyromental Distance Ratio as a Predictor of Difficult Intubation

Background: Pre-operative airway assessment for predicting difficult intubation is of utmost importance for anaesthesiologists to ensure adequate oxygenation and ventilation which is a priority.&#x0D; Aims &amp; Objectives: To evaluate the effectiveness of neck circumference (NC) to thyromental distance (TMD) ratio (NC/TMD) as a predictor of difficult intubation and its correlation with established predictors namely Mallampatti grading (MPC grading), Modified Cormack Lehane’s Score (MCLS grading).&#x0D; Methods: 140 patients of age between 18 to 60 years with ASA I, II were selected. Pre-operative, MPC grading and NC to TMD ratio was measured. Intra-operatively, MCLS grading, time taken for intubation, number of attempts taken for intubation, any additional use of equipment required and grading ease of intubation were noted. Correlation was done between them.&#x0D; Results: Out of 140 patients, NC/TMD ratio of &gt;5 was found in 20 patients in which 19 patients required an adjuvant during intubation. NC/TMD ratio had significantly higher sensitivity (75.20) and specificity (99.02) as compared to sensitivity (56.31) and specificity (92.38) of MPC grading. ROC curve for NC/TMD ratio had higher area under curve (AUC = 0.74) than Mallampatti grading (AUC = 0.66).&#x0D; Conclusion: As compared to MPC grading, NC/TMD has emerged out as a better predictor of difficult intubation.

Clinical Audit on the Quality of Pre-Anaesthesia Assessment based on Predefined Pre-anaesthesia Assessment Form

Objective: To determine the percentage completion of individual GQI indicators and the overall percentage of completed predefined Pre-anaesthesia assessment forms and identify any areas for improvement in the documentation of pre-anaesthesia assessment. Study Design: Cross-sectional study. Place and Duration of Study: Department of Anaesthesiology, Combined Military Hospital, Sialkot Pakistan, from Mar to Sep 2021. Methodology: Patients who reported to the operation theatre during the study period for elective surgery after having undergone formal pre-anaesthesia assessment preoperatively based on predefined Pre-anaesthesia assessment form (PAAF) were included. The quality of Pre-anaesthesia assessments from completion was assessed using a modified Global Quality Index with twenty-seven components. Results: The overall completion rate for all pre-anaesthesia assessment form components was 77.10±30.26%. The lowest completed items were local examination (0.00%), airway assessment, neck mobility, mouth opening, thyromental distance (24,10.61%), weight (25, 11.36%), GIT (86, 38.64%) and CNS/GCS (108, 48.48%) assessment, pre-operative vitals (121, 54.55%) and family history (129, 58.33%). Conclusion: We need to improve the quality of pre-anaesthesia assessment forms at our institution by ensuring that all relevant information is collected and documented.

Assessment of Different Indices as Predictors of Difficult Airway in Obese Patients.

Introduction Difficulties with tracheal intubation contribute to the morbidity and mortality associated with anesthesia. Suggested predictors for difficult airwayinclude, history of obstructive sleep apnea, high Mallampati score, elderly, male, short neck, and high Wilson score.However, none of these has high diagnostic accuracy particularly in obese population. Parameters used to quantify obesity such as Body Mass Index(BMI), mid arm circumference, skin fold thickness,etc. have not been used as independent predictors of difficult airway. This study has been designed to evaluate the accuracy of commonly used tools to assess difficult airway and to test other obesity markers as scale for assessing difficult airway i.e. Bag mask ventilation grade ≥3 or Cormack-Lehane Grade≥3 on Direct Laryngoscopy or number of intubation attempts ≥3. Aim To assess BMI, Mallampati grading, Neck circumference and Thyromental distance as predictors of difficult airway in obese patients and to validate neck circumference to thyromental distance ratio and skin fold thickness as a tool for assessment of difficult airway (Bag mask ventilation grade ≥3 or Cormack-Lehane Grade≥3 on Direct Laryngoscopy or number of intubation attempts ≥3.) in obese patients. Methods This prospective observational study was carried out on 51 obese patients (as per BMI) of ASA gradeII, either sex, aged 23 to 57 years posted for elective surgery under general anesthesia with endotracheal intubation. After subjective assessment of difficult airway following data sets and variables were obtained - sex, weight, height, body mass index (BMI),Modified Mallampati class (MPG), Cormack-Lehane (CL) grade, adequacy of bag mask ventilation (BMV), number of endotracheal intubation attempts, patient's neck circumference (NC), thyromental distance (TMD), waist-hip ratio (WHR) and Skin fold thickness. The observations made during the study were statistically analyzed and correlated as predictors for difficult airway. Result Correlation of MPG to CL-grade (r-0.41, p-0.003), BMV (r-0.31, p-0.028) & No. of intubationattempts (r-0.37, p-0.007) was mild & statistically significant. Correlation of Neck Circumference with CL-grade (r-0.57, p-0.000), & No. of intubation attempts (r-0.62, p-0.000), found moderate & statistically significant, & with BMV was mild and statistically significant (r-0.48, p-0.000). Correlation of Thyromental Distance to CL-grade (r-0.65, p-0.000), BMV (r-0.70, p-0.000) & No. of intubationattempts (r-0.61, p-0.000) was moderate & statistically significant. Correlation of BMI to CL-grade (r-0.11, p-0.428), BMV (r-0.04, p-0.757) & No. of intubation attempts (r-0.16, p-0.257) was weak & not significant. Skin Fold Thickness showed no significant association with Difficult airway i.e., CL Grade (p-0.478), BMV (p-0.101), and No. of intubation attempts (p-0.143). Correlation of NC/TMD ratio with BMV (r-0.74, p-0.000), CL-grade (r-0.76, p-0.000), & No. of intubation attempts (r-0.77, p-0.000) wasmoderate & statistically significant. Conclusion NC, TMDand NC/TMD Ratio depicted a close association with airway difficulty in obese patients. Obesity grade is a risk factor for difficult airway but predictors of obesity including Skin Fold Thickness, individually did not showassociation with difficult airway (small sample size may be a limiting factor). None of the commonly performed tests alone has proven to be adequate in predicting difficult intubation in the obese population.

A new score for airway assessment using clinical and ultrasound parameters.

Over the last few years, ultrasonography has been introduced as the fifth pillar to patient's bedside physical examination. Clinical assessments aim to screen and look for airway difficulties to predict difficult intubations, but none have demonstrated a significant predictive capacity. Recent systematic reviews have established a correlation between ultrasound imaging and difficult direct laryngoscopy. The primary objective of this study was to determine whether the utilization of ultrasonography to examine the upper airway could accurately predict difficult direct laryngoscopy. This is a prospective observational study including 102 adult patients that required general anesthesia for elective surgery. Preoperatively, clinical airway assessments were performed. Data such as Mallampati-Samsoon grade (MS), upper lip bite test (ULBT), thyromental (TMD) and sternomental distance (SMD), cervical circumference (CC) and the Arné risk index were collected. Ultrasound evaluation was taken at five different levels in two planes, parasagittal and transverse. Therefore, the following measurements were registered: distance from skin to hyoid bone (DSHB), distance from skin to thyrohyoid membrane (DSTHM), distance from skin to epiglottis (DSE), distance from skin to thyroid cartilage (DSTC) and distance from hyoid bone and thyroid cartilage (DHBTC). Patients were divided into two groups based on the difficulty to perform direct laryngoscopy, according to Cormack-Lehane (C-L) classification. Grades I and II were classified as easy laryngoscopy and grades III or IV as difficult. Logistic regression models and the Receiver Operating Characteristic (ROC) curve was employed to determine the diagnostic precision of ultrasound measurements to distinguish difficult laryngoscopy (DL). The following risk score for DL was obtained, DSTHM ≥ 1.60 cm (2 points), DSTC ≥ 0.78 cm (3 points) and gender (2 points for males). The score can range from 0 to 7 points, and showed and AUC (95% CI) of 0.84 (0.74-0.95). A score of 5 points or higher indicates a 34-fold increase in the risk of finding DL (p = 0.0010), sensitivity of 91.67, specificity of 75.56, positive predictive value of 33.33, and negative predictive value of 98.55. The use of ultrasonography combined with classic clinical screening tests are useful tools to predict difficult direct laryngoscopy.

Evaluation of Ultrasonography with Conventional Clinical Parameters for Predicting Difficult Laryngoscopy

Background: Unanticipated difficult intubation poses a challenge in routine practice for anaesthesiologists. A preoperative airway evaluation helps in the identification of a difficult airway. Airway assessment with ultrasound is a modality recently being used to predict difficult airway. In this study we evaluate ultrasonography parameters with conventional clinical parameters for predicting difficult airway in adults undergoing elective surgeries.&#x0D; Methods: This cross sectional randomised clinical trial analyses ASA class 1 and 2 adults requiring endotracheal intubation for surgeries under general anaesthesia were enrolled following which Modified Mallampatti score and thyromental distance as well as ultrasound distance to epiglottis (DSE) and distance to hyoid bone (DSHB) were measured and based on Cormack Lehane grading they were categorised into easy and difficult airway groups.&#x0D; Results: DSE had the highest sensitivity of 90.48% whereas Modified Mallampatti grading had least sensitivity of 66.67%.&#x0D; Conclusion: The results of this study showed that ultrasonographic measurements at the thyrohyoid and hyoid level have higher sensitivity and specificity than the clinical parameters for airway assessment.

A Comparison of Miller Straight Blade and Macintosh Blade Laryngoscopes for Intubation in Morbidly Obese Patients

The primary objective of this study was to demonstrate whether the Miller blade laryngoscope could provide better visualization of the vocal cords in morbidly obese patients than the Macintosh blade laryngoscope. The secondary objective was to identify the patient-measured factors associated with better visualization of the vocal cords when using the Miller vs. Macintosh blade, as well as whether the application of external pressure might improve the visibility of the glottis during intubation. A prospective, observational study encompassing 110 patients with a BMI &gt; 40 undergoing elective bariatric surgery and intubation procedure was performed. The evaluation of the vocal cords was performed according to the Cormack–Lehane scale and POGO scale in the same patient during intubation, performed with a Miller and a Macintosh blade laryngoscope, in a random matter. The following parameters were assessed: body weight, height, BMI, neck circumference, thyromental distance, sternomental distance, mouth opening, and Mallampati scale and their impact on visualization of the vocal cords using the Miller blade without the application of external pressure. The Miller blade provides an improved view of the glottis compared to the Macintosh blade measured with both the Cormac–Lehane scale (45 (40.91%) without external pressure application on the larynx, and 18 (16.36%) with external pressure application on the larynx) and the POGO scale (45 (40.91%) without external pressure application on the larynx, and 19 (17.27%) with external pressure application on the larynx). The application of laryngeal pressure improved the view of the glottis. Among the measured features, a significant improvement in the visibility of the glottis could be found in patients with a BMI over 44.244 kg/m2 and a neck circumference over 46 cm. To conclude, the usage of the Miller blade improves the visibility of the glottis compared to the Macintosh blade in morbidly obese patients. The recommendation to use the Miller blade in this group of patients requires further investigation, taking into account the effectiveness of the intubation. Trial Registration: NCT05494463.

Anesthesia for Craniotomy Tumor Removal Patient with Morbid Obesity

Purpose: Obesity is one of the greatest health challenges in the western world. Obesity is defined as a body mass index (BMI) &gt;30 kg/m2, with BMI &gt;35 and &gt;55 kg/m2 considered ‘morbidly’ obese and ‘super morbidly’ obese, respectively. The aim of this study was to examine anesthetic management for craniotomy tumor removal in patients with morbid obesity. Design/methodology/data analysis: This research uses a qualitative descriptive research method with a case study approach of a 39 year old female patient with a body weight of 110 kg, height 160 cm, and body mass index (BMI) 42.9 kg/m2, Mallampati score 2, thyromental distance &gt; 3 fingers hospitalized for removal of meningioma. Data collection techniques in this research used literature study, observation and laboratory tests. The data that has been collected is then analyzed descriptively. Findings: The results of the study showed that in the operating room, the patient was positioned in a neutral position 300 head up and Ramp. Preoxygenation with 100% O2 was performed via a face mask. Anesthesia was maintained with continuous intravenous propofol 25-50 μg/kg/min, intravenous rocuronium 40 mg/h, and volatile anesthesia using sevoflurane 0.5-1%vol with oxygen: air at a fraction of 50%. Monitoring during surgery includes evaluation of systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate, oxygen saturation, ECG waves, EtCO2, and urine output. The operation lasted 4 hours in the supine position. Post-surgery patients are then treated in the Intensive Care Unit (ICU) for one day before being transferred to the ward and finally to a regular room. He received treatment for 5 days before being discharged. Problems faced during anesthesia in obese patients are airway management, ventilation, position, drug dosage, presence of comorbidities and post-operative care for recovery from anesthesia and surgery. Originality/value: While addressing common challenges encountered during anesthesia in obese patients, this research takes a step further by proposing innovative solutions. The study acknowledges the complexities of airway management, ventilation, positioning, drug dosage, comorbidities, and post-operative care. However, it introduces novel considerations or techniques to mitigate these challenges, possibly involving emerging technologies or interdisciplinary collaboration for enhanced patient outcomes. Practical implications: The practical implications of this research advocate for a nuanced and individualized approach to anesthetic management in morbidly obese patients undergoing craniotomy tumor removal, fostering improved patient care and safety.

Comparison of video laryngoscope and direct laryngoscope for endotracheal intubation across different body mass index categories: A prospective study

The aim is to compare video laryngoscopy (VL) and Macintosh blade direct laryngoscopy according to the intubation difficulty scale (IDS) in patients with ASA 1 and Mallampati score I (C-MAC-D blade) according to body mass index (BMI). A total of 180 patients aged 18-70 years, scheduled for elective surgery under general anesthesia with ASA 1-2, Mallampati score I, and BMI&gt;18 kg/m² were included. DL and VL were performed in 50% of patients. Patients were randomly assigned to six groups based on BMI and laryngoscopy type. During intubation, data on the number of tubes used, number of anesthetists attempting intubation, number of alternative techniques employed, C-L score (C-L), laryngoscopy suspension power, application of external pressure, and vocal cord imaging were recorded, and IDS was calculated. Notable variations were detected in mouth opening, thyromental distance, and C-L and IDS levels across different laryngoscopy methods. Patients in the VL group exhibited a greater frequency of mouth opening of &lt;3 cm and thyromental distance of 6.5 cm (p=0.029 and p&lt;0.005, respectively). The VL group demonstrated higher rates of C-L=1 and easy IDS, whereas the DL group showed increased C-L=3 and mildly difficult-to-difficult IDS ratios (p=0.049 and p&lt;0.001, respectively). Within the BMI 25-30 kg/m² category, the VL group had a significantly larger number of patients with a thyromental distance &lt;6.5 cm (p=0.008). No substantial differences in mouth-opening measurements were observed between the groups. The intubation duration was extended in the VL group (p=0.019). The VL group displayed a higher frequency of easy IDS, whereas the DL group showed an increased rate of mild IDS (p =0.001). For patients with BMI &gt;30 kg/m², the VL group had considerably more individuals with a thyromental distance &lt;6.5 cm (p&lt;0.001). The DL group exhibited higher proportions of mildly difficult and difficult IDS, C-L=3 ratio, and prolonged intubation times (p&lt;0.001, p=0.026, p=0.028, respectively). In obese patients who undergo endotracheal intubation, better glottic visibility with the use of VL shortens the intubation time and makes the procedure easier.

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 (&gt;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

Prevalence of obstructive sleep apnea syndrome and predictors of difficult orotracheal intubation.

Obstructive sleep apnea syndrome (OSAS) is an underdiagnosed condition that causes recurrent episodes of partial or total collapse of the upper airways during sleep. It is associated with perioperative pulmonary complications. The STOP-BANG is a screening tool for assessing patients at risk of OSAS. The aim of this study was to assess the prevalence of patients with OSAS during pre-anesthetic evaluation at a hospital and its correlation with predictors of ventilation and difficult airway. This is an observational, cross-sectional study carried out from January 2022 to September 2023. The questionnaire comprised demographic data (age, weight, BMI, type of surgery, and anesthesia), the STOP-BANG, predictors of difficult orotracheal intubation (Mallampati, mouth opening, thyromental distance, cervical mobility, and upper lip bite test), and predictors of difficult ventilation through a facial mask (male sex, absence of teeth, presence of beard, obesity, and >55 years). The study had the participation of 221 patients, of whom 121 presented with a STOP-BANG ≥3, with a prevalence of 54.2%. All patients undergoing bariatric surgeries presented STOP-BANG ≥3. No significant statistical relationships were found between predictors of difficult orotracheal intubation and STOP-BANG ≥3. However, significant statistical relationships were found in relation to predictors of difficult ventilation through the facial mask.

Pilot multicenter study to determine the utility of point-of-care ultrasound to predict difficulty of tracheal intubation using videolaryngoscopy with the McGrath™ Mac videolaryngoscope.

Clinical airway screening tests used to predict difficulties during airway management have low sensitivity and specificity. Point-of-care airway ultrasound has described measurements related to problems with difficult direct laryngoscopy. Nevertheless, the correlation between ultrasound parameters and videolaryngoscopy has not been published yet. The aim of this multicenter, prospective observational pilot study was to evaluate the applicability of clinical parameters and ultrasound measurements to find potential tracheal intubation difficulties when videolaryngoscopy is used. Preoperatively, six clinical airway assessments were performed: (1) modified Mallampati score, (2) thyromental distance, (3) sternomental distance, (4) interincisal distance, (5) upper lip bite test, and (6) neck circumference. Six ultrasound parameters were measured in awake patients: (1) distance from skin to hyoid bone, (2) distance from skin to epiglottis, (3) hyomental distance in neutral head position, (4) hyomental distance in head-extended position, (5) distance from skin to the deepest part of the palate, and (6) sagittal tongue area. And finally, there was one ultrasound measure obtained in anesthetized patients, the compressed sagittal tongue area during videolaryngoscopy. The difficulty for tracheal intubation using a McGrath™ Mac videolaryngoscope, the percentage of glottic opening, and Cormack-Lehane grade were also assessed. In this cohort of 119 subjects, tongue dimensions, particularly the sagittal tongue area, showed a robust association with increased intubation difficulty using videolaryngoscopy. A multiparametric model combining the following three ultrasound variables in awake patients: (a) the distance from skin to epiglottis, (b) the distance from skin to the deepest part of the palate, and (c) the sagittal tongue area, yielded a sensitivity of 92.3%, specificity of 94.5%, positive predictive value of 82.8%, and negative predictive value of 97.8% (p < 0.001). Point-of-care airway ultrasound emerges as a more useful tool compared to traditional clinical scales to anticipate possible challenges during videolaryngoscopic intubation.

Ultrasound Versus Conventional Methods (Mallampati Score and Thyromental Distance) for Prediction of Difficult Airway in Adult Patient without Anticipated Difficult Airway

Ultrasound Versus Conventional Methods (Mallampati Score and Thyromental Distance) for Prediction of Difficult Airway in Adult Patient without Anticipated Difficult Airway

Goldenhar syndrome: An ephialte for the anesthesiologist – What we saw was just the tip of the iceberg

Goldenhar syndrome, also called oculoauriculovertebral dysplasia, is characterized by craniofacial, central nervous system, cardiac, renal, and vertebral anomalies. It occurs due to the faulty unilateral development of vertebral arches. Patients presenting for surgery are usually in the pediatric age group. General anesthesia is the preferred mode of anesthesia considering the type of surgery, age of the patient, and vertebral anomaly in this patient group. The first and foremost consideration while anesthetizing these patients is the anticipated difficult airway. Frequently encountered airway abnormalities in these patients are micrognathia, retrognathia, mandibular dysplasia, craniovertebral anomalies leading to limited neck flexion and cervical spine instability, decreased thyromental distance, fascial asymmetry, cleft lip and palate, high arched palate, dental abnormalities, and temporomandibular joint abnormalities. Difficult airways often come disguised as syndromes, and thorough pre-operative evaluation along with preparation for the worst scenarios is a must. We have a myriad of alternative airway management equipment at our disposal. Adequate knowledge is a must for their best use.

COMPARISON OF TOTAL AIRWAY SCORES AND INTUBATION DIFFICULTY SCORES IN DENTAL PROCEDURES PERFORMED UNDER GENERAL ANESTHESIA: A RETROSPECTIVE STUDY

The Total Airway Score, determined by eight bedside tests during the preoperative period, and the Intubation Difficulty Scale, assigned during intubation, are both used to describe and predict difficult intubation. The aim of this study is to investigate the correlation between the Total Airway Score and the Intubation Difficulty Scale.Two hundred,American Society of Anesthesiologists ASA 1-3 patients elective dental treatment, maxillofacial surgery under general anesthesia were included in the study. Airway evaluation was performed preoperatively by total airway score which were; Mallampati classification, thyromental and sternomental distance measurement, head and neck mobility,body mass index (BMI), presence of buck teeth, inter incisors gap, upper lip bite test. After endotracheal intubation, the patients were divided into two groups as a healthy group (intubation difficulty scale (IDS)&amp;lt;4) and difficult intubation (IDS ≥4) according to their estimated difficult intubation scores with seven variables and compared with patients with total airway score &amp;gt; 3 in two groups. In this study, total airway score (&amp;gt; 3), thyromental distance (&amp;lt;6cm), upper lip bite test (class III), mallampati classification (≥ class III), inter incisors gap (&amp;lt;3 cm) and buck teeth (&amp;gt; 0.5) respectively 49.45 (95% CI = 4.75-515.45, P &amp;lt;0.05) 7.72 (95% CI = 1.81-32.9, P &amp;lt;0.05), 21.12 (95% CI = 2.31-192.27, P &amp;lt;0.05), 1.92 (CI 95% = 0.51-7.22), 3.54 (95% CI-) 2.31 (95% CI = 0.49-10.78) was detected.It is concluded that total airway score (&amp;gt; 3), upper lip bite test (class III),thyromental distance measurement (&amp;lt;6 cm), which we use in predicting difficult intubation are the most useful preoperative evaluation factors.

Evaluation of Thyromental Height Test for Predicting Difficult Laryngoscopy in Morbid Obese Patients Candidate for Bariatric Surgery: An Observational Study

Upper airway management in morbid obese patients undergoing bariatric surgery is a major challenge during induction of anesthesia. Bed side Thyromental Height Test (TMHT) is an easy and valid predictor for prediction of difficult airway in non‑obese patients, but its precision in morbid obese patients haven’t been evaluated yet. The purpose of present study is to find the accuracy of TMHT for the prediction of difficult laryngoscopy in morbid obese patients undergoing bariatric surgery. The present prospective observational study was performed on 95 morbid obese patients at Sina hospital during 2020. Preoperative exams of patients include the assessment of Mallampati classification, thyromental height, thyromental, sternomental and interincisor distances. After induction of anesthesia, the laryngoscopy view was evaluated using the Cormack Lehane classification, and the relationship between these tests to prediction of difficult laryngoscopy view based on the Cormack Lehane degrees (grades 3,4) were evaluated. A total of 95 morbid obese patients with a mean BMI of 44.7±5.6 kg/m2.were included in the study. 67.3% of them were women. The incidence of difficult laryngoscopy (C &amp; L III, IV) was 16.8%. TMHT less than 56.5 mm, with 98% positive predictive value and 93% accuracy was the best predictor of difficult intubation in these patients. The accuracy of thyromental, sternomental and interincisor distance, with cut off value less than 51.5 mm, 89.5 mm, 41.5 mm respectively was less than TMHT in prediction of difficult laryngoscopy in morbid obese patients. In morbid obese patients with a BMI greater than 40, thyromental height less than 56.5 mm with 98% positive predictive value and 93% accuracy is the best predictor for difficult laryngoscopy view.