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Diagnostic Predictor of Difficult Laryngoscopy: The

Hyomental Distance Ratio


Jin Huh, MD*
Hwa-Yong Shin, MD
Seong-Hyop Kim, MD
Tae-Kyoon Yoon, MD
Duk-Kyung Kim, MD

BACKGROUND: We evaluated the usefulness of the hyomental distance (HMD) ratio


(HMDR), defined as the ratio of the HMD at the extreme of head extension to that
in the neutral position, in predicting difficult visualization of the larynx (DVL) in
apparently normal patients, by examining the following preoperative airway
predictors, alone and in combination: the modified Mallampati test, HMD in the
neutral position, HMD and thyromental distance at the extreme of head extension
and HMDR.
METHODS: Preoperatively, we assessed the five airway predictors in 213 adult
patients undergoing general anesthesia with tracheal intubation. A single experienced anesthesiologist, blinded to the results of the airway evaluation, performed
all of the direct laryngoscopies and graded the views using the modified Cormack
and Lehane scale. DVL was defined as a Grade 3 or 4 view. The optimal cutoff
points for each test were determined at the maximal point of the area under the
curve in the receiver operating characteristic curve. For the modified Mallampati
test, Class 3 was predefined as a predictor of DVL.
RESULTS: The larynx was difficult to visualize in 26 (12.2%) patients. In univariate
analyses, the HMD and thyromental distance at the extreme of head extension and
the HMDR were significantly related to DVL. The HMDR with the optimal cutoff
point of 1.2 had greater diagnostic accuracy (area under the curve of 0.782), than
other single predictors (P 0.05), and it alone showed a greater diagnostic validity
profile (sensitivity, 88%; specificity, 60%) than any test combinations.
CONCLUSIONS: The HMDR with a test threshold of 1.2 is a clinically reliable predictor
of DVL.
(Anesth Analg 2009;108:544 8)

ifficult visualization of the larynx (DVL) is a


major cause of difficult intubation in many patients.1
Therefore, preoperative identification of those patients
at risk for difficult laryngoscopy is important in adopting safer alternative strategies for the induction of
anesthesia and intubation. However, whether true
prediction is possible and which variables should be
used for evaluation remain subjects of debate.
The hyomental distance (HMD) has been used to
estimate the mandibular space, but the HMD alone
was shown to have only a modest degree of diagnostic
accuracy.2 Recently, Takenaka et al.3 defined the ratio
of the HMD in the neutral position and at the extreme
of head extension as the hyomental distance ratio

From the *Department of Anesthesiology, Seoul National University Borame Municipal Hospital; and Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine,
Seoul, South Korea.
Accepted for publication August 5, 2008.
Address correspondence and reprint requests to Duk-Kyung Kim,
MD, Department of Anesthesiology and Pain Medicine, Konkuk
University School of Medicine, 1 Hwayang-Dong, Gwanggin-Gu,
Seoul 143-701, South Korea. Address e-mail to dikei@kuh.ac.kr.
Copyright 2009 International Anesthesia Research Society
DOI: 10.1213/ane.0b013e31818fc347

544

(HMDR) and demonstrated that it was a good predictor of a reduced occipitoatlantoaxial (OAA) complex
extension capacity in patients with rheumatoid arthritis. In a cinefluoroscopic study,4 the OAA extension
angle required to expose the glottis during direct
laryngoscopy was found to be at least 12. On the
other hand, Hastings and Wood5 measured the OAA
extension angles with an external angle finder affixed
to the head of normal subjects and demonstrated its
value as 23. In the study of Urakami et al.,6 the OAA
extension capacity could not exceed 23 in approximately two thirds of the 20 normal subjects. Therefore,
we believe that there are some cases in which the
angle for an optimal laryngoscopic view cannot exceed the extension capacity, even in apparently normal patients. In such cases, optimal visualization of
the glottis would require maximal head extension
during laryngoscopic intubation. Thus, an assessment
of the extension capacity of the OAA complex is an
important component of preoperative tests for predicting DVL. However, no study has quantified its
diagnostic validity for predicting DVL. The purpose of
the present study was to evaluate the usefulness of the
HMDR for accurately predicting DVL in apparently
normal patients, by examining the following preoperative airway predictors, alone and in combination:
the modified Mallampati test, HMD in the neutral
Vol. 108, No. 2, February 2009

Figure 1. Method for measuring the


hyomental distance ratio (HMDR).
The HMDR was defined as the ratio
of the hyomental distance (HMD) at
the extreme of head extension (expressed as HMD*) to that in the neutral position (expressed as HMD).
Thyromental distance (TMD) at the
extreme of head extension was expressed as TMD*.

position, HMD and thyromental distance (TMD) at the


extreme of head extension, and HMDR.

METHODS
The study protocol was approved by the hospital
ethics committee, and written informed consent was
obtained from all of the participating patients. We
studied 213 consecutive adult patients scheduled to
undergo general anesthesia requiring tracheal intubation for elective surgery. Exclusion criteria included a
gross anatomical abnormality, recent surgery of the
head and neck, upper airway disease (e.g., maxillofacial fracture or tumors), loose teeth, or those requiring
a rapid sequence or awake intubation.
All testing was performed by a single investigator
who was well trained in our planned test but not
involved in intubating the trachea. As one of the
comparative airway evaluation tests, we initially performed the modified Mallampati test.7 Subsequently,
we kept the patients in the supine position, with the
head on a firm operating table. The patients were
instructed to look straight ahead, keep the head in the
neutral position, close the mouth and not swallow. A
hard-plastic bond ruler was pressed on the skin surface just above the hyoid bone, and the distance from
the tip to the anterior-most part of the mentum was
measured and defined as the HMD in the neutral
position (Fig. 1). The patients were then instructed to
extend the head maximally, taking care that the shoulders were not lifted while extending the head. The
HMD was measured again in this position, and this
variable was defined as the HMD at the extreme of
head extension. Using the same method in this position, the straight distance from the anterior-most part
of the mentum to the thyroid notch was measured and
defined as the TMD at the extreme of head extension
(Fig. 1). The HMDR was calculated as the ratio of the
HMD at the extreme of head extension to that in the
neutral position.
After all of the airway evaluations were completed,
standard monitors were applied, and anesthesia was
induced with fentanyl 1 g/kg, thiopental 57 mg/kg,
and vecuronium 0.1 mg/kg to facilitate tracheal intubation. Laryngoscopy was performed after the loss of
the fourth twitch in the train-of-four in response to
Vol. 108, No. 2, February 2009

ulnar nerve stimulation. All laryngoscopies were performed with the patient placed in the sniffing position8 (head placed on a 6-cm firm pad with a gel ring)
using a #4 Macintosh blade. A single experienced
anesthesiologist, blinded to the results of the airway
assessments, performed all of the direct laryngoscopies and classified the laryngoscopic view according
to the modified Cormack and Lehane grade (C-L
grade).9 Easy visualization of the larynx was defined
as a Grade 1 or 2 view, and DVL was a Grade 3 or 4
view on direct laryngoscopy.
The following statistical analyses were performed
with MedCal 7.3 for Windows (MedCal software,
Mariakerke, Belgium). First, a univariate analysis
was performed to assess the association of each
demographic parameter and airway predictor with
DVL. An unpaired t-test was used for continuous
variables, and the 2 test or Fishers exact test, as
appropriate, was used for noncontinuous variables.
Second, the receiver operating characteristic (ROC)
curves were constructed to explore the trade-offs
between the sensitivity and specificity of each test.
The ROC area under the curve (AUC), which ranges
from 0.5 to 1.0, equals the probability of correctly
predicting DVL.10 Therefore, the optimal cutoff
points of each test were determined at the maximum
of the AUC for the corresponding ROC curve. For
the modified Mallampati test, Grade 3 or 4 was
predefined as a predictor of DVL.11 Third, using
these cutoff points, true and false positives, true and
false negatives, and the sensitivity, specificity, positive predictive value, and negative predictive value
of each test were calculated. Then, all possible
combinations of the modified Mallampati test and
single predictors that were shown to be relevant to
DVL in the univariate analysis were formulated,
and the diagnostic validity profiles were calculated
and compared among the combinations. Lastly, the
diagnostic accuracy of the HMDR versus that of the
other proven single predictors was assessed by
calculating the AUC for each ROC curve. The AUC
is a performance indicator equivalent to the nonparametric concordance measure, Somers D, and the
difference between two ROC areas is half the difference between the corresponding Somers D values.12
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545

Table 1. Univariate Analysis of the Variables Affecting


Laryngoscopy Difficulty
EVL
(n 187)
Sex (M/F)
Age (yr)
Weight (kg)
Height (cm)
BMI (kg/m2)
Modified Mallampati
class
Easy (Class 1 or 2)/
difficult (Class 3 or 4)
TMD at the extreme of
head extension (cm)
HMD in the neutral
position (cm)
HMD at the extreme of
head extension (cm)
HMDR

DVL
(n 26)

99/88
10/16
46.0 16.2 51.8 12.9
63.7 10.6 63.1 9.6
163.9 8.7 161.1 7.1
23.6 2.7
24.2 3.2
175/12

23/3

P
NS
NS
NS
NS
NS
NS

7.2 0.7

6.8 0.7

0.003

4.6 0.6

4.7 0.7

NS

5.8 0.5

5.5 0.7

0.015

1.3 0.1

1.2 0.1

0.000

Values are expressed as means SD or numbers.


EVL easy visualization of larynx (modified Cormack and Lehane Grade 1 or 2); DVL
difficult visualization of larynx (modified Cormack and Lehane Grade 3 or 4); BMI body
mass index; HMD hyomental distance; HMDR hyomental distance ratio; TMD
thyromental distance.

The AUC values were compared using the nonparametric method of Delong et al.,13 which is based on
the MannWhitney U statistic. In all cases, statistical
significance was defined as P 0.05.

RESULTS
The larynx was difficult to visualize in 26 (12.2%) of
the 213 patients (Table 1). No failed tracheal intubations occurred. In the univariate analysis, significant
differences were observed in the HMD and TMD at
the extreme of head extension and in the HMDR
between the DVL and easy visualization of the larynx
patients (Table 1).
The diagnostic validity profiles from the single tests
for the derived test criteria are shown in Table 2. The
HMDR, with a sensitivity of 88%, was the most
sensitive of the single tests. Combinations of the three
tests that were relevant to DVL in the univariate
analyses and the modified Mallampati test resulted in
increased specificity at the expense of decreasing the
sensitivity. Although the HMDR and the HMD at the
extreme of head extension was the combination with
the best result, it showed a poorer diagnostic validity
profile than the HMDR alone (Table 3).
The ROC curves of the three single predictors that
were relevant to DVL in the univariate analyses are
shown in Figure 2. The AUC values for the HMD and
TMD at the extreme of head extension were 0.642 and
0.659, indicating a poor degree of accuracy. In comparison, the AUC for the HMDR was significantly
greater, at 0.782 (Table 4; Fig. 2).

DISCUSSION
The incidence of DVL in this study was 12.2%,
which is consistent with a meta-analysis of nine studies that included 14,438 patients and a DVL incidence
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Predictor of Difficult Laryngoscopy

of 6%27%.14 The wide variations in the incidence of


DVL may be related to factors such as age11 and ethnic
differences among patients15,16 or types of laryngoscope blade used.17 Based on a ROC curve analysis of
the variables statistically relevant to DVL, the HMDR
using an optimal cutoff point of 1.2 had the highest
diagnostic accuracy for predicting DVL, with an AUC
of 0.782 (95% confidence interval, 0.720 0.835). According to published guidelines,18 the HMDR was the
only single test with good diagnostic value (AUC of
0.75 0.92). The HMDR alone had a greater diagnostic
validity profile than that of the modified Mallampati
test combined with any of the variables statistically
relevant to DVL.
The major advantage of the HMDR is its high
sensitivity (88%), which minimizes false-negative predictions. However, the HMDR has relative low specificity (60%) and positive predictive value (23%). The
high false-positive predictions based on this test may
subject many patients to unnecessary procedures. The
ideal test for DVL prediction should have 100% sensitivity and 100% specificity; however, sensitivity and
specificity are inversely proportional to each other.
We believe that minimizing false-negative predictions
with the HMDR is preferable to minimizing falsepositive predictions, because the higher numbers of
false-negative predictions that would be associated
with minimizing false-positive predictions may lead
to the potentially serious scenario of failed intubation.
The HMDR was previously suggested as a new
possible predictor of DVL,3 and we confirmed its
utility in the present study. Radiological studies4,19
revealed that the HMD increased during extension of
the head at the OAA complex and remained so during
extension of the head in the subaxial regions. This
means that the hyoid bone moves parallel to the
cervical spine during movement of the head and neck.
As a result, the HMDR alone was highly correlated
with the OAA complex extension capacity despite a
concurrent degree of subaxial extension.3 In addition, the HMDR is easy and quick to perform at
bedside without any special devices and was found
to be more accurate than direct measurement of the
OAA complex extension angle using a gogglesmounted goniometer.3,6
During laryngoscopy, creating a nearly straight line
from the mouth to the glottic opening depends entirely on the degree of extension of the OAA complex.6,20 The angle required to expose the glottis
during direct laryngoscopy was previously reported
to be at least 12,4 and the corresponding HMDR was
calculated as 1.25.3 Therefore, we prepared a plain or
optical stylet, laryngeal mask airway, or fiberoptic
scope in such cases and planned to adopt these
alternative strategies if the first intubation trial were to
fail. As a result, our calculated cutoff point of 1.2 is
similar to that of the original version of the HMDR. As
both cutoff points are derived from a similar ethnic
ANESTHESIA & ANALGESIA

Table 2. Diagnostic Validity Profiles of Five Airway Assessment Tests for Predicting Difficult Laryngoscopy (n)
Airway assessment test
Modified Mallampati Class 3
HMD in the neutral position 5.5 cm
HMD at the extreme of head
extension 5.3 cm
TMD at the extreme of head
extension 6.2 cm
HMDR 1.2

TP TN FP FN Sensitivity (%) Specificity (%) PPV (%) NPV (%)


3
6
12

175
178
152

12
9
35

23
20
14

12
23
46

94
95
81

20
40
26

88
90
92

172

15

18

31

92

35

91

23

112

75

88

60

23

97

HMD hyomental distance; HMDR hyomental distance ratio; TMD thyromental distance; TP true positive; TN true negative; FP false positive; FN false negative; PPV positive
predictive value; NPV negative predictive value.

Table 3. Diagnostic Validity Profiles of Airway Assessment Test Combinations for Predicting Difficult Laryngoscopy
Airway assessment test
HMDR
HMDR
HMDR
HMDR
HMDR
HMDR
HMDR
HMDR

Sensitivity (%)

Specificity (%)

PPV (%)

NPV (%)

88
12
42
27
23
8
0
0

60
98
94
97
98
99
100
100

23
50
48
54
67
67
0/0
0/0

97
89
92
91
90
89
88
88

MMT
HMDextension
TMDextension
HMDextension TMDextension
HMDextension MMT
TMDextension MMT
HMDextension TMDextension MMT

HMDR hyomental distance ratio; MMT modified Mallampati test; HMDextension hyomental distance at the extreme of head extension; TMDextension thyromental distance at the extreme
of head extension; PPV positive predictive value; NPV negative predictive value.

Table 4. Receiver Operating Characteristic (ROC) Curve


Analysis of Airway Assessment Tests for Predicting
Difficult Laryngoscopy
Airway assessment
test
HMD at the extreme of
head extension 5.3 cm
TMD at the extreme of
head extension 6.2 cm
HMDR 1.2

AUC

SE

95% CI

0.642

0.053

0.5730.706

0.659

0.052

0.5910.723

0.782*

0.040

0.7200.835

HMD hyomental distance; TMD thyromental distance; HMDR hyomental distance


ratio; AUC area under the curve in each ROC curve; SE standard error; CI confidence
interval.
* Significantly different from the other tests (P 0.05).

Figure 2. Receiver operating characteristic curves for the


hyomental distance (HMD) and thyromental distance (TMD)
at the extreme of head extension and the hyomental distance
ratio (HMDR). Squares (f) indicate the optimal cutoff points of
each test.

group (i.e., East Asians), there is a clear need for more


data on the HMDR in different ethnic groups.
Instead of the sitting position used in the original
version of the study describing the HMDR, we kept
the patients in the supine position during the measurement for several reasons. First, it is reasonable to
evaluate the airway in the position in which laryngoscopic intubation will actually be performed. Because
the hyoid bone is movable, the possibility of changes
in its dimension and position because of the effect of
gravity should be taken into consideration. Recently,
Sutthiprapaporn et al.21 demonstrated that the body of
Vol. 108, No. 2, February 2009

the hyoid bone moves caudally 6.7 4.4 mm in


response to a change in the postural position from
supine to sitting upright. Considering the significant
degree of intersubject variability in the vertical hyoid
bone movement, anatomic variables related to the
hyoid bone are more predictive when measuring in
the supine position, rather than in the sitting position.
Second, our method may be more useful in the intensive care unit or general ward, where clinicians encounter patients lying in bed in need of intubation.
These patients are usually connected to many monitoring instruments, drains, and IV lines; thus, several
medical personnel and a great deal of time may be
required to keep the patients in a sitting position for
the tests. Third, our method may be applicable to
patients who cannot sit up in bed or control their head
and neck because of altered levels of consciousness.
Although we did not measure the HMD on manual
maximal extension of the head, this maneuver could
replace voluntary maximal extension by the patients.
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There are some potential limitations to our study


design. First, intersubject variability was possible because the end point for extending the head maximally
depended on the voluntary participation of each subject. We tried to clearly explain each maneuver to the
patients and demonstrated it when necessary; thus,
we believe that intersubject variability was of minor
importance in this study. Second, intrarater variability
was possible, because a single investigator performed all
of the measurements at once in a test. Finally, although
DVL is a major determinant of difficult intubation, it is
not synonymous with difficult intubation. In this study,
we defined the modified C-L Grade 3 or 4 as an indicator
of DVL. In many clinical situations, however, the application of external laryngeal pressure facilitates a laryngoscopic view and intubation can be performed without
difficulty in these patients. In addition, direct laryngoscopy is not the only way to secure and maintain an
airway, although it is the most common means of
facilitating intubation.
In conclusion, we demonstrated that the HMDR is a
clinically reliable predictor of DVL and that a value of
1.2 can be used as a test threshold. Although the
HMDR test alone had greater diagnostic accuracy than
any combination of the tests in this study, it had
relatively low specificity and a high number of falsepositive results. Therefore, we recommend seeking an
optimal combination of tests that includes the HMDR
and other predictors and performing the tests in
combination, rather than using it alone.
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ANESTHESIA & ANALGESIA