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LETTER TO THE EDITOR

The Upper Lip Bite Test to Predict Difficult Intubation

Department of Anesthesiology; Imam Khomeini Medical Center; School of Medicine, Medical Sciences/ University of Tehran; Keshavarz Blvd, Tehran 14197, Iran; khanhzh51{at}yahoo.com

In Response:

Regarding Tong et al.'s1 referral to Figure 2 in our article,2 obliteration of the lower lip has never been cited as an essential requirement in performing the Mallampati test as described by Mallampati et al.,3 and later as modified by Samsoon et al.4 The tongue can lie well within the oral cavity and fall short of obliterating the lower lip despite a maximal effort on the part of the patient. Our patient had a tongue tie and was unable to protrude the tongue maximally. We do agree with Tong et al. that single screening tests should be avoided to curtail the chances of low predictive values. Finally, "forward movement of the mandible according to the position of the lower incisors in relation to the upper incisors" has been discussed in our original study.5

We agree with Dr. Rosenblatt6 and should have provided evidence confirming our assertion that the patient's trachea was easily intubated. Unfortunately, a picture of the laryngeal view was not taken to demonstrate to the readers that the glottic view was easily obtained at the first attempt, within 20 s, and graded as 1 according to Cormack and Lehane's grading system.7

Finally, although we provided a guarded opinion about prediction of laryngoscopy in such potentially difficult cases as the one we reported taking into consideration the possibility that our management could have resulted in a "can't intubate, ventilate or oxygenate situation," we do agree with each author1,6,8 that the safest approach should have been awake tracheal intubation preferably utilizing a fiberscope.

REFERENCES

1. Tong JL, Gait AJ. The upper lip bite test to predict difficult intubation. Anesth Analg 2008;106:668–9[Free Full Text]
2. Khan ZH, Gharabaghian M, Nilli F, Ghiamat M, Mohammadi M. Easy endotracheal intubation of a patient suffering from both Cushing's and Nelson's syndromes predicted by the upper lip bite test despite a Mallampati class 4 airway. Anesth Analg 2007;105:786–7[Abstract/Free Full Text]
3. Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, Liu PL. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985;32:429–34[Web of Science][Medline]
4. Samsoon GLT, Young JRB. Difficult tracheal intubation: a retrospective study. Anaesthesia 1987;42:487–90[Web of Science][Medline]
5. Khan ZH, Kashfi A, Ebrahimkhani E. A comparison of the upper lip bite test (a simple new technique) with modified Mallampati classification in predicting difficulty in endotracheal intubation: a prospective blinded study. Anesth Analg 2003;96:595–9[Abstract/Free Full Text]
6. Rosenblatt WH. Interesting anecdotes cannot validate test results. Anesth Analg 2008;106:668[Free Full Text]
7. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39:1105–11[Web of Science][Medline]
8. Law JA. Relying on just a few predictors of easy airway management may bite back! Anesth Analg 2008;106:668[Free Full Text]

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