BRIEF REPORT

The Incidence of Class Zero Airway and the Impact of

Mallampati Score, Age, Sex, and Body Mass Index on
Prediction of Laryngoscopy Grade
Tiberiu Ezri, MD*, R. David Warters, MD, Peter Szmuk, MD, Husam Saad-Eddin,
Daniel Geva, MD, Jeffrey Katz, MD, and Carin Hagberg, MD

MD,

*Department of Anesthesiology, Wolfson Medical Center, Holon, Affiliated with Sackler Medical School, Tel-Aviv, Israel;
University of Texas, Houston Medical School, Houston, TX; and the Kaplan Medical Center, Rehovot, Affiliated with
Hadassah Medical School, Jerusalem, Israel

he ability of a specific test (i.e., the Mallampati

scoring system) to predict a difficult intubation is
decreased by the variability of definitions of difficult intubation/laryngoscopy (1 4) and the inherent
inaccuracy of numeric grading systems (5). However,
the Mallampati scoring system is still widely used to
evaluate airways before surgery. Ezri et al. (6) and
Maleck et al. (7) have described a new class of airway
view, class zero, and propose to add this class to the
four modified Mallampati classes.
This study estimates the incidence of class zero airway, determines the ability of a class zero view to
predict laryngoscopy grade, and assesses the effect of
the airway classes, age, sex, body mass index (BMI),
and other factors on the prediction of the laryngoscopy grade.

Methods
During a 2-mo period, all patients greater than 18 yr of
age who spent time in the preoperative holding area
between 8:00 am and 4:00 pm were enrolled in this
prospective study. With approval of the institutional
ethics committee from the University of Texas at
Houston, informed consent was obtained before each
assessment. We excluded patients receiving regional
anesthesia and patients receiving general anesthesia
without endotracheal intubation. Also excluded were
patients with upper airway pathology (i.e., maxillofacial fractures, tumors, etc.), cervical spine fractures,
and increased risk for aspiration of gastric contents.
Presented in part at the annual meeting of the American Society
of Anesthesia, San Francisco, CA, October, 2000.
Accepted for publication May 15, 2001.
Address correspondence and reprint requests to Peter Szmuk,
The University of Texas, Houston Medical School, Department of
Anesthesiology, 6431 Fannin, MSB 5.020, Houston, TX 77030. Address e-mail to Peter.Szmuk@uth.tmc.edu.
2001 by the International Anesthesia Research Society
0003-2999/01

The airway class was assessed according to the

Samsoon and Young (8) modification of Mallampatis
classification.
We added class zero (6) to the four classes of the
Mallampati system. Class zero is defined as the ability
to see any part of the epiglottis upon mouth opening
and tongue protrusion (Fig. 1). All the airway assessments were done by the same anesthesiologist, in the
sitting position, with the patients head in neutral
position, mouth fully open, tongue fully extended,
and without phonation.
Previous difficult laryngoscopy, protruding upper
teeth, loose teeth, thyro-mental distance 6 cm, interincisor gap 3 cm, and limited neck extension were
also recorded and correlated with airway classes 3 and
4 and laryngoscopy grade III. Laryngoscopy was performed in sniffing position with a Macintosh blade,
and stylettes were routinely used in the endotracheal
tubes. The laryngoscopy grade was assessed by an
attending anesthesiologist by using the Cormack and
Lehane grading scale (9). Difficult laryngoscopy was
defined as grade III or IV laryngoscopy.
After 5 min of preoxygenation, anesthesia was induced with fentanyl (1 g/kg), thiopental (3 mg/kg),
and rocuronium (0.6 mg/kg). Patients with a BMI 35
received succinylcholine (1 mg/kg) for endotracheal
intubation.
Analysis of variance tests were used to determine
whether there were any significant differences in age,
BMI, airway classes, and laryngoscopy grades. Students t-tests were performed to determine whether
there were significant differences in age and BMI for
pairwise comparison, and 2 or Fishers exact tests
were performed to determine whether there were significant differences in sex among classes and grades.
Linear regression analysis was performed to determine whether there was a significant trend in age or
BMI as airway class and laryngoscopy grade increased. Cochran-Armitage trend tests were used to
Anesth Analg 2001;93:10735

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BRIEF REPORT

ANESTH ANALG
2001;93:10735

Table 1. Distribution of Age, Body Mass Index, and Sex

Among Airway Classes and Laryngoscopy Grades

Class
0
1
2
3
4
Grade
I
II
III
Figure 1. Class zero airway: the epiglottis is seen at the back of the
mouth view.

determine whether male sex was correlated with an

increase in airway class and laryngoscopy grade. Logistic regression analysis was performed to determine
the independence of each factor in predicting difficult
laryngoscopy.

Results
A total of 764 patients (52% men, aged 44.4 17 yr,
BMI 28 8, mean sd) were enrolled in the study.
Class zero airway occurred in 1.18% of patients.
Thirty-five percent of the patients had class 3 or 4
airways, and 10.6% demonstrated a laryngoscopy
grade of III. The distribution of age, sex, and BMI
among the five classes and three grades is presented in
Table 1. Older mean ages were observed in those
patients with airway class 4 and laryngoscopy grade
III (57 and 53 yr, respectively).
Table 2 shows the statistical significance of the differences in age, BMI, and sex between the classes and
grades. All patients with class zero airways were
women. Laryngoscopy grade III occurred twice as
frequently in males as in females. There was a significant correlation between increased class with increased age and BMI. An increase in age but not BMI
was associated with high laryngoscopy grade.
Table 3 depicts the correlation between classes and
grades. All patients with class zero airways had a
grade I laryngoscopy. Class 1 airway was associated
with 10.9% grade II and 3.2% grade III laryngoscopy.
There is a stepwise increase in the incidence of laryngoscopy grade III as the airway class changes from 2 to
3 and from 3 to 4. Classes 3 and 4 had a sensitivity,
specificity and positive and negative predictive values
of 84%, 71%, 97%, and 26%, respectively, for a grade
III laryngoscopy view. With stepwise logistic regression analysis, positive associations of grade III laryngoscopy were found with increased age, male sex,

Sex

Age (yr)

Body mass
index

Male

Female

31 (1938)
39 (1854)
45 (2063)
48 (3265)
57 (4570)

24 7
27 8
27 6
29 7
41 23

0
11
22.5
17.7
0.8

1.2
9.4
21.2
14.9
1.2

41 (2558)
46 (3565)
53 (3875)

28 9
28 6
29 8

21.8
23.2
7.1

23.7
20.7
3.5

Values are expressed as mean (range), mean sd, or percentage of total

(764 cases).

Table 2. Statistical Significance of the Correlation

Between Classes and Grades Versus Age, Body Mass
Index, and Sex
Variable
Class
0 vs 1
0 vs 2
0 vs 3
0 vs 4
1 vs 2
1 vs 3
1 vs 4
2 vs 3
2 vs 4
3 vs 4
Grade
I vs II
I vs III
II vs III

Age

Body mass
index

Sex

0.106
0.023
0.002
0.0001
0.0003
0.0001
0.0001
0.027
0.006
0.019

0.245
0.154
0.047
0.019
0.683
0.017
0.041
0.0002
0.0001
0.0001

0.001
0.002
0.001
0.052
0.628
0.942
0.305
0.515
0.384
0.284

0.0001
0.0001
0.0007

0.918
0.278
0.226

0.192
0.002
0.025

Numbers represent P values. P 0.05 was considered statistically significant.

Chi-square test or Fishers exact test were used for categoric variables
(class, grade, and sex), and Students t-test was used for continuous variables
(age and body mass index).

Table 3. Distribution of the Four Laryngoscopy Grades

Among the Five Airway Classes
Grade
Class

II

III

IV

0
1
2
3
4

9 (100%)
134 (85%)
155 (46.3%)
48 (19.3%)
2 (13.3%)

0
17 (10.9%)
172 (51.3%)
144 (57.8%)
2 (13.3%)

0
5 (3.2%)
8 (2.4)
57 (22.9%)
11 (73.3%)

0%
0%
0%
0%
0%

Number of cases (percentage of the total number of patients from each

class and the respective grade).

protruding upper teeth, loose teeth, and increased

airway class (Table 4). The incidence of failed intubation or ventilation, as well as grade IV laryngoscopy
view, was zero.

ANESTH ANALG
2001;93:10735

BRIEF REPORT

1075

Table 4. Stepwise Logistic Regression: Laryngoscopy Grade III Versus Grade I and II
Variable

Variable estimate

se

P value

Odds ratio

Age
Male
Protruding upper teeth
Loose teeth
Airway class

0.0248
0.7995
1.5172
1.4759
1.7714

0.00812
0.2781
0.7475
0.6827
0.2350

0.0022
0.004
0.0424
0.0306
0.0001

1.05
2.224
4.559
4.375
5.879

Discussion
In this study the incidence of class zero airway was
1.18%. All patients with class zero airways were
women and had grade I laryngoscopy. The fact that all
patients with class zero airways were women may be
explained by differences in neck fat deposition between the sexes, as demonstrated in a magnetic resonance imaging study by Whittle et al. (10). This may
also explain the larger percentage of difficult laryngoscopies found in our male patients.
As the airway class increased, so did the laryngoscopy grade (Table 3). The 10- to 30-fold increase in the
incidence of grade III from classes 0 2 to classes 3 and
4 is in agreement with the results of Mallampati et al.
(11), which showed that of the 15 patients with class 3
(15 of 210 patients, 7.14%) airways, 60% had grade III
laryngoscopy, compared with none in class 1.
Some studies have shown obesity to be a risk factor for
difficult intubation (12,13), yet others (14,15) have found
that the incidence of difficult intubation in morbidly
obese patients is not more frequent than in normal subjects. In our patients, an increased BMI was not correlated with a high laryngoscopy grade. By using magnetic
resonance imaging measurements in obese patients with
and without obstructive sleep apnea, Horner et al. (16)
found more fatty tissues in areas surrounding the collapsible segments of the pharynx in patients with sleep
apnea. This may explain why some obese patients are
easy to intubate or ventilate and others are not.
Age between 40 and 59 years may carry a risk for
difficult intubation (13). In our study, an increase in age
was consistent with increase in both airway classes and
laryngoscopy grades. Osteoarthritic changes and poor
dentition may explain the age-related difficult
laryngoscopy.
Logistic regression analysis revealed that grade III
laryngoscopy had a positive correlation with advanced age, male sex, protruding upper teeth, loose
teeth, and increased airway class, but not with BMI,
interincisor distance, or thyro-mental distance.
The 71% specificity of the Mallampati test demonstrates that 29% of our patients who were not Mallampati 3 and 4 still experienced a difficult laryngoscopy.
Combined with the low positive predictive value, this
suggests that for a better prediction of difficult intubation, the Mallampati scoring should be combined with
other predictors.

Class zero airway had an incidence of 1.18% and

proved to be an excellent predictor of grade I laryngoscopy. All patients with class zero airways were
women. Class 1 airway was not as good as class zero
for predicting an easy intubation. An airway class 2
was a good predictor of difficult laryngoscopy (grade
III). An increased laryngoscopy grade had a positive
correlation with increased age, male sex, protruding
upper teeth, loose teeth, and increased airway class,
but not with increased BMI.
We thank Professor Jacques Chelly and Dr. Sam Lurie for their
support in preparing this manuscript.

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