Ultrasound to detect difficult laryngoscopy

A pilot study suggests sonographic measurements of neck soft tissue thickness may predict difficult laryngoscopy. Laryngoscopy was difficult in patients with increased thickness of the anterior neck soft tissue at the level of the hyoid bone and thyrohyoid membrane. The authors suggest that anterior neck soft tissue thickness cutoff value of 2.8 cm at the thyrohyoid membrane level can potentially be used to detect difficult laryngoscopy, but that this would require further validation since in this pilot study there were only six subjects in the difficult laryngoscopy group.

Objectives:  Prediction of difficult laryngoscopy in emergency care settings is challenging. The preintubation clinical screening tests may not be applied in a large number of emergency intubations due to the patient’s clinical condition. The objectives of this study were 1) to determine the utility of sonographic measurements of thickness of the tongue, anterior neck soft tissue at the level of the hyoid bone, and thyrohyoid membrane in distinguishing difficult and easy laryngoscopies and 2) to examine the association between sonographic measurements (thickness of tongue and anterior neck soft tissue) and difficult airway clinical screening tests (modified Mallampati score, thyromental distance, and interincisor gap).

Methods:  This was a prospective observational study at an academic medical center. Adult patients undergoing endotracheal intubation for an elective surgical procedure were included. The investigators involved in data collection were blinded to each other’s assessments. Demographic variables were collected preoperatively. The clinical screening tests to predict a difficult airway were performed. The ultrasound (US) measurements of tongue and anterior neck soft tissue were obtained. The laryngoscopic view was graded using Cormack and Lehane classification by anesthesia providers on the day of surgery. To allow for comparisons between difficult airway and easy airway groups, a two-sided Student’s t-test and Fisher’s exact test were employed as appropriate. Spearman’s rank correlation coefficients were used to examine the association between screening tests and sonographic measurements.

Results:  The mean (±standard deviation [SD]) age of 51 eligible patients (32 female, 19 male) was 53.1 (±13.2) years. Six of the 51 patients (12%, 95% confidence interval [CI] = 3% to 20%) were classified as having difficult laryngoscopy by anesthesia providers. The distribution of laryngoscopy grades for all subjects was 63, 25, 4, and 8% for grades 1, 2, 3, and 4, respectively. In this study, 83% of subjects with difficult airways were males. No other significant differences were noted in the demographic variables and difficult airway clinical screening tests between the two groups. The sonographic measurements of anterior neck soft tissue were greater in the difficult laryngoscopy group compared to the easy laryngoscopy group at the level of the hyoid bone (1.69, 95% CI = 1.19 to 2.19 vs. 1.37, 95% CI = 1.27 to 1.46) and thyrohyoid membrane (3.47, 95% CI = 2.88 to 4.07 vs. 2.37, 95% CI = 2.29 to 2.44). No significant correlation was found between sonographic measurements and clinical screening tests.

Conclusions:  This pilot study demonstrated that sonographic measurements of anterior neck soft tissue thickness at the level of hyoid bone and thyrohyoid membrane can be used to distinguish difficult and easy laryngoscopies. Clinical screening tests did not correlate with US measurements, and US was able to detect difficult laryngoscopy, indicating the limitations of the conventional screening tests for predicting difficult laryngoscopy.

Pilot Study to Determine the Utility of Point-of-care Ultrasound in the Assessment of Difficult Laryngoscopy
Acad Emerg Med. 2011 Jul;18(7):754-8

One thought on “Ultrasound to detect difficult laryngoscopy”

  1. This is an interesting idea, and worth looking into properly, but there’s something funny about the abstract (maybe explained in the full text, can’t access it). 8% grade 4 laryngoscopy is enormous- never heard anywhere near this for experienced anaesthetists in an unselected population. And from the figures presented, more than 25% of male patients had a ‘difficult laryngoscopy’! What was their definition of difficult?!

    If their ultrasound threshold picks up this kind of difficulty, I doubt it’s much more sensitive for genuine difficulty than even the most cursory clinical exam…

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