Development of a scoring system for predicting difficult intubation using ultrasonography

BACKGROUND AND AIMS: Ultrasound measurement of anterior neck soft tissue thickness by skin to epiglottis distance (SED) has been shown to predict difficult laryngoscopy. In this study, we developed an airway scoring system incorporating SED into three clinical predictors and assessed whether it would improve accuracy in prediction of difficult intubation. METHODS: Mentohyoid distance, mandibular subluxation, head extension and ultrasound measurement of skin to epiglottis distance were measured a day before surgery in 310 adult patients. During direct laryngoscopy, Cormack–Lehane grading was noted (Grade 1 and 2 = Easy, Grade 3 and 4 = Difficult). We constructed a score named MSH, which included mentohyoid distance, mandibular subluxation and head extension. Then, SED was added to the MSH score to form another new score named U(SED)-MSH. Student's t-test, Mann-Whitney U test and Chi-square test or Fisher exact tests were used. Both scoring systems were compared under the receiver-operating characteristic curve and area under the curve (AUC) were calculated. RESULTS: Difficult intubation was observed in 62/310 patients (20%). The AUC for U(SED)-MSH score was greater than the MSH score (0.93, 95% CI [0.89–0.97] vs 0.76, 95% CI [0.69–0.84], P value <0.001). U(SED)-MSH score had higher sensitivity (93.6% vs 59.7%) and lower specificity (85.9% vs 91.1%) with similar positive predictive value (62.7% vs 62.4%) in comparison with MSH score. CONCLUSION: An airway scoring system using the ultrasound measurements of skin-to-epiglottis distance along with the clinical predictors would be helpful in the prediction of difficult intubation.