Mallampati Class Zero Airway in a 5-yr-old Child.

Dear Sir,

Mallampati class zero airway, described as ‘visible epiglottis upon mouth opening and tongue protrusion’, is a recently popularised entity in adults, with a reported incidence of approximately 1.18%.1 It is infrequently reported in children.23 Two anaesthetic procedures with Mallampati zero airway have been reported in a 9-yr-old boy.2 Both endotracheal intubation and insertion of laryngeal mask airway was easy in this child. Another 6-yr-old boy with class zero airway on preoperative examination has been reported, but, he did not undergo any surgery.3 Mask ventilation, laryngoscopy, and tracheal intubation in children with class zero airway may be challenging, due to associated stiff and elongated epiglottis in paediatric patients. We report our anaesthetic experience in a 5-yr-old child; probably the youngest reported till date, with a Mallampati zero airway. This girl weighed 22 kg and was scheduled for laminectomy and release of tethered spinal cord under anaesthesia. Airway examination revealed visible epiglottis (Fig 1). Rest of the clinical examination was unremarkable. Anaesthesia was induced with fentanyl and propofol. Laryngoscopy was performed using a curved Macintosh blade # 2 which revealed a grade I laryngoscopic view. The airway was secured in first attempt with uncuffed 5.0 mm I.D orotracheal tube. The perioperative course was uneventful.

Figure 1

Visible epiglottis on mouth opening (arrow)

A higher probable incidence of class zero airways has been suggested in children owing to anteriorly placed larynx.4 However, no data is available at present to substantiate this claim. In adults, experience of variable airway difficulties has been reported in relation to class zero airway.15 However, such problems were never encountered in managing paediatric class zero airways reported till date, including this case. Hence, larger studies would be required to know the exact incidence and associated difficulty, if any, in managing this unique paediatric airway.