European Journal of Cardiovascular Medicine

Unanticipated difficult laryngoscopy and tracheal intubation constitute a persistent concern in clinical anaesthesia, with reported incidence varying between 0.1 % and 18 % in apparently normal patients [1–3]. Ineffective preparation and prediction can result in airways injuries, hypoxic brain damages, or even death [4, 5]. Therefore, pre-operative assessment of airways constitutes a component of harmless anaesthetic practice.

Among the tools that are used as the predictive tests that include thyromental distance, the sterna mental distance, the neck mobility, and the mouth opening, the most freely used screening test when at a bedside is the Modified Mallampati that classification. It has been suggested by Mallampati et al. (1985) and with some modifications by Samsoon and Young (1987) [6, 7] and categorizes the oropharyngeal look upon the instance that the patient opens his or her mouth and thrusts his tongue. High larynx coming out (III, IV) is linked to great opportunities of problematic laryngoscopy.

Despite its simplicity, the test’s reliability is affected by patient cooperation, head position, lighting, and observer experience [8]. Traditionally performed in the sitting posture, the MMC may not be feasible for all patients—such as trauma victims, parturients, or those with spinal immobilisation. For these patients, a supine assessment is often performed, though its predictive validity remains controversial [9].

Previous investigators have reported variable results. Tham et al. [10] and Oates et al. [11] observed that posture and phonation could alter Mallampati grading, whereas Bindra et al. [12] found minimal positional influence. Singhal et al. [13] demonstrated that the supine position improved the Mallampati class by one grade in many subjects, possibly due to gravitational displacement of soft tissues. Conversely, Lewis et al. [14] noted that phonation and tongue movement introduced observer inconsistency.

The current analysis was designed based on such inconsistencies and the vast amount of information available on these populations of India to assess the efficacy of Mallampati grading in the descending position and upright position in drawing conclusions related to the challenging laryngoscopy and intubation among adult patients in the elective surgical. We hypothesized that supine assessment would yield comparative predictive worth bearing in mind upright pose and, as such, would be acceptable when the upright position assessment is impractical.

Study Design and Setting The research was to be a prospective cross-sectional study on the department of anesthesiology at Sri Devaraj Urs medical college, Sri Devaraj Urs academy of higher education and research, Tamaka, Kolar, India in accordance to a research proposal which had passed the Institutional Ethics Committee. The study was carried out over a six-month duration of time. Participants Adults over the age of 18 years (ASA physical condition 1-2) were identified and informed written consent were signed beforehand in order to engage in informed consent 30 patients were to undergo a general anaesthesia under tracheal intubation in order to undergo elective operation. Inclusion criteria: • ASA I and II • Age ≥ 18 years • Elective surgical procedures under general anaesthesia Exclusion criteria: • ASA III and IV • Paediatric, obese (BMI > 30 kg/m²) or uncooperative patients • Known or suspected airway pathology, restricted neck movement, upper cervical spine anomalies, or cranio-vertebral junction abnormalities • Patients planned for awake or fibreoptic intubation Methodology Each patient underwent airway assessment by the same investigator to minimise inter-observer variability. The Modified Mallampati Class (MMC) was recorded in both upright and supine postures: • Upright posture: patient seated, head in neutral position, mouth opened maximally, tongue protruded without phonation. • Supine posture: patient lying on the operating table with a 10 cm pillow under the head, identical mouth opening and tongue protrusion. Oropharyngeal view was graded as: I – Soft palate, fauces, uvula, pillars visible II – Soft palate, fauces, uvula visible III – Soft palate, base of uvula visible IV – Only hard palate visible Grades I–II were considered easy, and III–IV difficult for intubation prediction. Anaesthetic Technique and Laryngoscopy Every patient starved overnight and was pre-medicated. Intravenous thiopentone (450-500mg/kg) and fentanyl (2 -0ug/kg) induced anaesthesia following pre-oxygenation. Atracurium (0.5mg/kg) was used to achieve muscle relaxation. An experienced anaesthesiologist who had no vision of Mallampati outcomes carried out laryngoscopy after obtuse relaxation with the aid of usual Macintosh blade. Laryngoscopic visualization was graded-based on Cormack-Lehane (CL) system: I – Full view of glottis; II – Partial view; III – Epiglottis only; IV – Neither epiglottis nor glottis visible. Grades I–II were labelled easy, and III–IV difficult laryngoscopy. Statistical Analysis After tabulation, the information was entered in the Microsoft Excel spreadsheet and calculated in the IBM SPSS v22. The categorical variables were in percentages and frequencies as well, and continuous data in terms of means and SD. They computed sensibility, specificity, PPV, NPV, accuracy, and Cohen K coefficient upright and supine MMC in prediction of problematic laryngoscopy. The level of statistical significance was considered to be P 0.05.

Demographic Profile                                                                                                                                                            

The study cohort comprised 30 patients: 16 males (53.3%) and 14 females (46.7%), mean age 38.6 ± 10.4 years, mean BMI 24.7 ± 3.1 kg/m². Twenty-three patients (76.7%) were ASA I and seven (23.3%) ASA II.

Table 1 presents baseline demographic characteristics.

Table 1: Demographic characteristics (n = 30)

Mallampati Grading in Upright vs Supine Positions

Mallampati class distribution differed slightly between positions (Table 2). The supine posture yielded a higher frequency of Class III–IV (26.6%) compared with upright (20%), indicating mild upward shift in grading.

Table 2: Distribution of Mallampati classes in upright and supine positions

Laryngoscopy Findings

During direct laryngoscopy, 3 (10%) patients exhibited difficult views (CL grade III); none were grade IV. All were intubated successfully using external laryngeal pressure.

The correlation between Mallampati class and Cormack–Lehane grade is summarised in Table 3.

Table 3: Diagnostic performance of Mallampati test in predicting difficult laryngoscopy

Figures

FIGURE 1. COMPARISON OF DIFFICULT MALLAMPATI CLASSES (III–IV) BETWEEN POSITIONS

FIGURE 2. ROC CURVES FOR MALLAMPATI GRADING IN UPRIGHT AND SUPINE POSITIONS

Difficult tracheal intubation remains one of the principal causes of anaesthetic morbidity, making reliable pre-operative airway assessment indispensable [1, 2]. The Modified Mallampati classification continues to be the most practical screening test, despite known variability [6, 8]. Our study compared its efficacy in upright and supine postures among elective surgical patients and found both to have comparable predictive validity, with marginally superior specificity for the supine posture.

The incidence of difficult laryngoscopy (10%) in this series aligns with earlier reports by Rose and Cohen [15] and Shiga et al. [1]. Supine assessment revealed slightly higher Mallampati grades, consistent with observations by Singhal et al. [13], who attributed the change to gravitational posterior displacement of the tongue and soft palate. Similarly, Bindra et al. [12] reported minimal but consistent elevation of Mallampati class in supine posture without compromising predictive accuracy.

In our findings, specificity and PPV improved in the supine position, indicating fewer false positives and better identification of truly difficult cases. This corroborates Khan et al. [16] who observed higher specificity for the supine Mallampati test when combined with phonation. The slight reduction in sensitivity reflects a tendency to under-diagnose marginally difficult laryngoscopies, which, however, are less clinically consequential when NPV remains high (> 95%).

The test’s diagnostic accuracy (AUC ≈ 0.88) compares favourably with large meta-analyses [17] that documented pooled sensitivity 50–60 % and specificity 80–90 %. The observed κ = 0.42 for supine assessment indicates moderate agreement with laryngoscopic view, reinforcing its clinical acceptability.

Physiologically, the supine posture reduces the gravitational pull on the tongue and soft palate, altering the oropharyngeal geometry. This may expose a smaller

portion of the pharynx, leading to higher Mallampati grades. However, from a practical perspective, many pre-operative assessments occur in the ward or pre-anaesthesia area where the patient is recumbent; thus, supine evaluation provides valuable predictive information without requiring postural adjustment.

Our findings contrast slightly with those of Oates et al. [11] and Lewis et al. [14], who emphasised the variability introduced by phonation and head extension. Since phonation was avoided in our protocol, we minimised this confounder. Additionally, the small sample size and homogeneous ASA I–II population may explain the absence of statistically significant differences between postures.

From a clinical standpoint, performing Mallampati grading in both positions can enhance the anaesthesiologist’s preparedness. In patients unable to sit upright—trauma, pregnancy, spinal or neurosurgical cases—the supine assessment can confidently substitute the traditional test.

Limitations

The limitations of the study are that it has a small size (n = 30), is designed as a single centre, and has nothing to indicate inter-observer variability. In addition, we failed to measure composite airway predictors like thyromental distance or neck circumference, which may help to increase predictive accuracy. These findings can be concluded by future multicentric studies with larger cohorts to support them.

The Mallampati testing conducted in the supine position has the same information about tricky laryngoscopy and intubation as a traditional method, which used the upright position. Supine assessment does have slightly greater specificity and congruence with Cormack Lehane grade and so is a useful alternative where it is not possible to use the upright position. Overall, the test does not lose its high negative predictive value, as shown in both cases, providing a firm statement about the application of the test as a simple and efficient airway screening measure.

1.             Markos, Z., Melese, E., Getachew, L., & Haddis, L. Comparison of Mallampati test in sitting position and in supine position for prediction of difficult tracheal intubation among adult patients who underwent surgery under general anesthesia at Addis Ababa governmental hospitals 2021, comparative cross-sectional study. Annals of Medicine and Surgery 2022; 82: 104711.

2.             Khan, Z. H., Eskandari, S., & Yekaninejad, M. S. A comparison of the Mallampati test in supine and upright positions with and without phonation in predicting difficult laryngoscopy and intubation: A prospective study. Journal of Anaesthesiology Clinical Pharmacology 2015;31(2): 207-211.

3.             Hanouz, J. L., Bonnet, V., Buléon, C., Simonet, T., Radenac, D., Zamparini, G,Gérard, J. L. Comparison of the Mallampati classification in sitting and supine position to predict difficult tracheal intubation: a prospective observational cohort study. Anesthesia & Analgesia 2018;126(1): 161-169.

4.             Yirga, S., Samuel, H., Markos, Z., & Yohannes, W. (2025). Comparison of modified Mallampati test with and without phonation for prediction of difficult laryngoscopy and intubation among adult surgical patients: cross-sectional study. Annals of Medicine and Surgery 2025;87(1):85-92.

5.             Amaniti, A., Papakonstantinou, P., Gkinas, D., Dalakakis, I., Papapostolou, E., Nikopoulou, A etal.  Comparison of laryngoscopic views between C-MAC™ and conventional laryngoscopy in patients with multiple preoperative prognostic criteria of difficult intubation. An observational cross-sectional study. Medicina 2019; 55(12): 760.

6.             Kotwani, M., Kawale, N. N., Nam, P. B., & Kotwani, D.  Modified Mallampati Test in Supine versus Sitting Position as a Predictor for Difficult Intubation–An Observational Study. Airway 2024; 7(2):64-70.

7.             Ahirwar, A., Kumar, S., & Kumar, A.  Modified Mallampati Test as A Predictor for Difficultyin Intubationin Supine Versus Sitting Position-An Observational Prospective Study. European Journal of Cardiovascular Medicine 2025; 15:656-660.

8.             Niikuni N, Nakajima I, Akasaka M. The relationship between tongue-base position and craniofacial morphology in preschool children. J Clin Pediatr Dent. 2004 Winter;28(2):131-4.

9.             Prakash, S., Mullick, P., & Singh, R.  Evaluation of thyromental height as a predictor of difficult laryngoscopy and difficult intubation: a cross-sectional observational study. Brazilian Journal of Anesthesiology (English Edition)2022; 72(6): 742-748.

10.          Andruszkiewicz, P., Wojtczak, J., Sobczyk, D., Stach, O., & Kowalik, I.  Effectiveness and validity of sonographic upper airway evaluation to predict difficult laryngoscopy. Journal of ultrasound in medicine 2016; 35(10): 2243-2252.

11.          Nair P, Mulimani S, Mantur J, Suntan A. Evaluation of Ultrasonography with Conventional Clinical Parameters for Predicting Difficult Laryngoscopy. Arch Anesth & Crit Care. 2023;10(1):36-42.

12.          Falsafi R,Shafikani A, Nasseh N,Kayalha H. Relationship betweenupper airway ultrasound parameters and degree of difficultlaryngoscopy forendotracheal intubation. J cell Mol Anaesth 2022;8(1):e 150201.

13.          Park S, Hong J, Park JW, Han SH, Kim JH. Comparison of Simple Stylet versus Lighted Stylet for Intubating the Trachea with a Direct Laryngoscope: A Randomized Clinical Trial. J Clin Med. 2019 Jan 25;8(2):140.

14.          Nurullah, M., Alam, M. S., Hossen, M., & Shahnawaz, M. (2018). Prediction of difficult airway by thyromental height test-a comparison with modified mallampati test. Bangladesh Journal of Medical Science 2018; 17(3): 455-461.

15.          Parameswari A, Govind M, Vakamudi M. Correlation between preoperative ultrasonographic airway assessment and laryngoscopic view in adult patients: A prospective study. J Anaesthesiol Clin Pharmacol. 2017 Jul-Sep;33(3):353-358.

16.          Yu, J. L., & Rosen, I. (2020). Utility of the modified Mallampati grade and Friedman tongue position in the assessment of obstructive sleep apnea. Journal of Clinical Sleep Medicine 2020; 16(2):303-308.

17.          Xia M, Ma W, Zuo M, Deng X, Xue F, Battaglini D etal. Expert consensus on difficult airway assessment. Hepatobiliary Surg Nutr. 2023 Aug 1;12(4):545-566.