title: Assessment of difficult laryngoscopy by electronically measured maxillo-pharyngeal angle on lateral cervical radiograph: A prospective study.
abstract: BACKGROUND
  Difficult airway continued to be a major cause of anesthesia-related morbidity and mortality. Successful airway management depends on direct laryngoscopy and tracheal intubation. Difficult laryngoscopy is a resultant of incomplete structural arrangements during the process of head positioning. Through clinical history, examination of the patients along with craniofacial indices alerts the anesthetist for difficult laryngoscopy. But it does not predict all causes of difficult laryngoscopy during pre-anesthetic evaluation. The maxillo-pharyngeal angle, an upper airway anatomical balance, was proposed for better understanding the pathophysiology of difficult laryngoscopy. In our study we have assess difficult laryngoscopy by electronically measuring maxillo-pharyngeal angles on a lateral cervical radiograph. This angle is normally greater than 100°. Less than 90° angle suggests either impossible or difficult direct laryngoscopy when all known craniofacial indices were within the normal range. Cervical radiographic assessment is a simple, economical, and non-invasive predictive method for difficult laryngoscopy. It should be used routinely along with other indices as pre-anesthetic airway assessment criteria to predict the difficult laryngoscopy.
  
  
  BACKGROUND
  Difficulties with airway management continue to be a major cause of anesthesia-related morbidity, mortality, and litigation. Pre-operative assessment of difficult laryngoscopy by the simple and non-invasive radiological method can help to prevent them.
  
  
  OBJECTIVE
  To assess the difficult laryngoscopy pre operatively by a simple and non invasive radiological method by electronically measuring maxillo-pharyngeal angle on a lateral cervical radiograph and it's correlation with Cormack and Lehane grading.
  
  
  METHODS
  This is a controlled, nonrandomized, prospective, cohort observation study.
  
  
  METHODS
  The 157 adult consented patients of ASA grade I to III of either sex, scheduled for elective surgery under general anesthesia with endo-tracheal intubation, were studied. The patients with identified difficult airway indices were excluded from the study. The maxillo-pharyngeal angle was electronically measured on a lateral cervical radiograph and was correlated with ease or difficulty of laryngoscopy under general anesthesia. Their degree of laryngeal exposure according to Cormack and Lehane classification grade was also noted.
  
  
  METHODS
  We performed univariate analyses to evaluate the association between the covariates and direct laryngoscopy.
  
  
  RESULTS
  In 148 patients (94.28%), the maxillo-pharyngeal angle was more than 100°, in 7 patients (4.45%) it was less than 90°, and in 2 patients (1.27%) the M-P angle was less than 85° with normal craniofacial indices. When the MP angle was less than 90°, the direct laryngoscopy was difficult which could be compared with to Cormack and Lehane classification grade III and IV.
  
  
  CONCLUSIONS
  Lateral cervical radiographic assessment should be used as pre-anesthetic airway assessment criteria to predict the difficult laryngoscopy as it is a simple, safe and non-invasive method.
authors.affiliation: Department of Anesthesiology & Critical Care, N.S.C.B.Subharti Medical College, Subhartipuram, NH-58, Meerut, Uttar Pradesh, India.
authors.forename: Kumkum
authors.initials: K
authors.lastname: Gupta
authors.forename: Prashant K
authors.initials: PK
authors.lastname: Gupta