the size and shape of the tongue and palate relative to the size of the mouth. the teeth, especially noting the presence of prominent maxillary incisors, any loose or damaged teeth, or crowns.Many classification systems have been developed in an effort to predict difficulty of tracheal intubation, including the Cormack-Lehane classification system, the Intubation Difficulty Scale (IDS), and the Mallampati score. The Mallampati score is drawn from the observation that the size of the base of the tongue influences the difficulty of intubation. It is determined by looking at the anatomy of the mouth, and in particular the visibility of the base of palatine uvula, faucial pillars and the soft palate. Although such medical scoring systems may aid in the evaluation of patients, no single score or combination of scores can be trusted to specifically detect all and only those patients who are difficult to intubate. Furthermore, one study of experienced anesthesiologists, on the widely used Cormack–Lehane classification system, found they did not score the same patients consistently over time, and that only 25% could correctly define all four grades of the widely used Cormack–Lehane classification system. Under certain emergency circumstances (e.g., severe head trauma or suspected cervical spine injury), it may be impossible to fully utilize these the physical examination and the various classification systems to predict the difficulty of tracheal intubation. A recent Cochrane systematic review examined the sensitivity and specificity of various bedside tests commonly used for predicting difficulty in airway management.
Use of the flexible fiberoptic bronchoscope and similar devices has become among the preferred techniques in the management of such cases. However, these devices require a different skill set than that employed for conventional laryngoscopy and are expensive to purchase, maintain and repair.When taking the patients medical history, the subject is questioned about any significant signs or symptoms, such as difficulty in speaking or difficulty in breathing. These may suggest obstructing lesions in various locations within the upper airway, larynx, or tracheobronchial tree. A history of previous surgery (e.g., previous cervical fusion), injury, radiation therapy, or tumors involving the head, neck and upper chest can also provide clues to a potentially difficult intubation. Previous experiences with tracheal intubation, especially difficult intubation, intubation for prolonged duration (e.g., intensive care unit) or prior tracheotomy are also noted.A detailed physical examination of the airway is important, particularly:
the range of motion of the cervical spine: the subject should be able to tilt the head back and then forward so that the chin touches the chest. the range of motion of the jaw (the temporomandibular joint): three of the subjects fingers should be able to fit between the upper and lower incisors. the size and shape of the upper jaw and lower jaw, looking especially for problems such as maxillary hypoplasia (an underdeveloped upper jaw), micrognathia (an abnormally small jaw), or retrognathia (misalignment of the upper and lower jaw). the thyromental distance: three of the subjects fingers should be able to fit between the Adams apple and the chin.