title: Lower flange modification improves performance of the Macintosh, but not the Miller laryngoscope blade.
abstract: OBJECTIVE
  In order to minimize the potential for dental damage and to improve laryngeal visualization during tracheal intubation, two commonly used laryngoscope blades were modified and compared in a clinical setting: the Miller laryngoscope blade and the Macintosh laryngoscope blade. Modified versions of both laryngoscope blades with a lowered heel (Callander modification) at the proximal end of the blade were compared to standard blades.
  
  
  METHODS
  Forty patients scheduled for general anesthesia requiring endotracheal intubation were studied prospectively. Preoperatively, the patients' airways were evaluated according to Mallampati score, thyromental distance and interincisor gap. After induction of anesthesia laryngoscopy was performed with the original laryngoscope and its modified counterpart in random order. A lateral x-ray of the neck was taken after the optimal view had been obtained, and blade-tooth distance, laryngeal view, blade-tooth contact and need for assistance were measured. Using angular calculations the laryngoscopes were analyzed at different insertion depths on graph paper, and the results were compared with data from the lateral x-rays.
  
  
  RESULTS
  With a modified Macintosh blade the blade-tooth distance was significantly greater in comparison to the original design (2.5 +/- 2.1 cm vs 0.2 +/- 0.1 cm, P < 0.01). Consequently the number of blade-tooth contacts was significantly lower (20% vs 75%, P < 0.05). The best laryngeal view could be obtained using a modified Macintosh laryngoscope. With a modified Miller laryngoscope laryngeal visibility was not improved and assistance was required more often to achieve adequate intubating conditions (35% vs 5%, P < 0.05).
  
  
  CONCLUSIONS
  A reduction of the proximal flange of a Miller blade decreases the blade's effectiveness for laryngeal visualization, whereas a similar modification of a Macintosh blade increases blade-tooth distance, decreases the number of blade-tooth contacts and provides a better laryngeal view.
authors.affiliation: Department of Anesthesiology and General Intensive Care, University of Vienna Medical School, A-1090 Vienna, Waehringer Guertel 18-20, Austria. study@kimberger.at
authors.forename: Oliver
authors.initials: O
authors.lastname: Kimberger
authors.forename: Lukas
authors.initials: L
authors.lastname: Fischer
authors.forename: Christina
authors.initials: C
authors.lastname: Plank
authors.forename: Nikolaus
authors.initials: N
authors.lastname: Mayer
mesh_terms: D000328:Adult; D000368:Aged; D000768:Anesthesia, General; D004867:Equipment Design; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal; D020704:Laryngoscopes / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D009333:Neck / Q000000981:diagnostic imaging; D011446:Prospective Studies; D011859:Radiography; D014070:Tooth / Q000033:anatomy & histology