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Logo of tjarTurkish Journal of Anaesthesiology and Reanimation
Turk J Anaesthesiol Reanim. 2014 June; 42(3): 160–161.
Published online 2014 June 1. doi:  10.5152/TJAR.2014.71602
PMCID: PMC4894228

Mallampati ‘Zero’ Airway: Extremely Easy or Not?

To the Editor,

An epiglottis that is seen during laryngoscopy is a relief for the anesthetist, but what should one feel if the epiglottis is seen by mouth opening, during Mallampati class examination? Since Ezri suggested to add a new class, ‘class zero airway,’ to the Mallampati classification (1), there has been a debate whether the epiglottis seen by mouth opening is a sign of ‘extremely’ easy intubation or not. There are no randomized, controlled studies assessing the ease of intubation of this class; so, prevalence studies and case reports become more important. Nevertheless, the results of them are varied and limited.

We want to present a (another) case of easy intubation with class zero airway and want to emphasize the importance of weight in the prediction of ease of intubation. A 27-year-old female, 47 kg and 163 cm, was admitted for rhinoplasty. Her epiglottis was seen during Mallampati examination (Figure 1), and her Cormack Lehane laryngoscopy grade was I. She was easily intubated in the first attempt.

Figure 1
View of Epiglottis in Mallampati Class Zero Airway

Tobolt in 1869 was the first to describe that the epiglottis might be seen during mouth opening, but he did not determine its incidence (2). By a literature review, we found 42 easy and 3 difficult intubations reported (Table 1) (313). One of the difficult intubations and 15 of the easy intubations were males. Some of the case reports and letters do not even mention the weight of the patients. In these reports, age and gender are more emphasized, but we think that weight is as important as they are.

Table 1
The ‘Mallampati zero’ cases in the English literature


1. Ezri T, Cohen I, Geva D, Szmuk P. Pharyngoscopic views. Anesth Analg. 1998;87:748. [PubMed]
2. Tobold A. Lehrbuch der Laryngoskopie. 2nd ed. Berlin: Hirschwald; 1869. p. 42.
3. Craig RG, Patwardhan A. An abnormal epiglottis but an easy intubation. Anaesthesia. 1998;53:1036. [PubMed]
4. Ezri T, Warters RD, Szmuk P, Saad-Eddin H, Geva D, Katz J, et al. The incidence of class “zero” airway and the impact of Mallampati score, age, sex, and body mass index on prediction of laryngoscopy grade. Anesth Analg. 2001;93:1073–5. [PubMed]
5. Shastri C, Mahapatro S, Masalgekar D, Sarkar MA. Mallampati class 0 airway. Anaesthesia. 2006;61:820–1. [PubMed]
6. Mahajan R, Grover VK. Intubating conditions associated with the Mallampati “class zero” airway. Can J Anaesth. 2005;52:891–2. [PubMed]
7. Sakuragi T, Hori K, Shiratake T, Miyawaki J, Ishida M. Tracheal intubation in an adult male with Mallampati class zero airway. Can J Anaesth. 2005;52:115–6. [PubMed]
8. Fang B, Norris J. Class zero airway and laryngoscopy. Anesth Analg. 2004;98:870–1. [PubMed]
9. Grover VK, Mahajan R, Tomar M. Class zero airway and laryngoscopy. Anesth Analg. 2003;96:911. [PubMed]
10. Xie X, Au-Truong X, Klowden AJ, Joseph NJ, Ramez Salem M. Mallampati class “Zero” Anesth Analg. 2002;94:1371. [PubMed]
11. Indira G. Mallampati class ‘zero’ - yet another cause? Indian J Anaesth. 2011;55:544–5. [PMC free article] [PubMed]
12. Hegde HV, Prasad KC, Bhat MT, Hegde JS, Santhosh Mysore Cb, Yaliwal VG, et al. Airway difficulty in Mallampati ‘class zero’ patients: a prospective double-blind observational study. Eur J Anaesthesiol. 2012;29:338–42. [PubMed]
13. Prabhakar H, Ali Z, Singh GP, Chaudhary P. Acromegalic and “Mallampati class zero” airway-an unusual finding! J Neurosurg Anesthesiol. 2010;22:79. [PubMed]

Articles from Turkish Journal of Anaesthesiology and Reanimation are provided here courtesy of Turkish Society of Anaesthesiology and Reanimation