title: Effect of mandibular tori on glottic exposure during simulated suspension microlaryngoscopy.
abstract: OBJECTIVE
  Mandibular tori have been identified as a contributing factor in difficult exposure during intubation. However, no investigation has measured the effect of mandibular tori on glottic exposure during suspension microlaryngoscopy (SML). The objective of this study was to measure how the size and location of mandibular tori affect glottic exposure during simulated SML at different thyromental distances.
  
  
  METHODS
  Suspension microlaryngoscopy was modeled on an anatomically accurate skull and larynx with thyromental distances between 6 and 12 cm. Mandibular tori were simulated by protruding screws 5 to 15 mm from the lingual aspect of the mandible. The tori were positioned either 15 mm (anterior) or 25 mm (posterior) from the midline of the symphysis. The glottic exposure for the various-size tori in each location was measured by recording the displacement of the glottiscope tip relative to the most anterior exposure achievable without tori. The glottiscope angle relative to the horizontal plane was measured for each condition.
  
  
  RESULTS
  Mandibular tori of more than 10 mm had a significant impact on glottic exposure. Displacement of the glottiscope tip ranged from 2 to 9 mm for anteriorly placed tori and from 7 to 29 mm for posteriorly placed tori, with larger tori causing greater displacement. Increasing the thyromental distance increased the posterior glottiscope tip displacement regardless of torus size or location. The glottiscope angle increased with larger tori (12º to 28º), but this angle did not change with increasing thyromental distance.
  
  
  CONCLUSIONS
  Larger size and more-posterior location of mandibular tori more significantly reduce glottic exposure during SML. The inner table of the mandible is the most relevant anatomic constraint on glottic exposure, which varies with the presence or absence of mandibular tori independent of thyromental distance.
authors.affiliation: Department of Surgery, Harvard Medical School, and the Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Simon R
authors.initials: SR
authors.lastname: Best
authors.forename: James B
authors.initials: JB
authors.lastname: Kobler
authors.forename: Aaron D
authors.initials: AD
authors.lastname: Friedman
authors.forename: Anca M
authors.initials: AM
authors.lastname: Barbu
authors.forename: Steven M
authors.initials: SM
authors.lastname: Zeitels
authors.forename: James A
authors.initials: JA
authors.lastname: Burns
mesh_terms: D005096:Exostoses / Q000150:complications*; D005931:Glottis / Q000473:pathology / Q000601:surgery*; D006801:Humans; D007828:Laryngoscopy / Q000379:methods*; D008336:Mandibular Diseases / Q000150:complications*; D008866:Microsurgery / Q000379:methods*; D008953:Models, Anatomic
keywords: difficult airway; difficult intubation; direct laryngoscopy; glottis; laryngoscope; larynx; mandibular tori; suspension microlaryngoscopy; vocal fold