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Pediatric class zero airway

Toronto, Ontario

To the Editor:

It has recently been suggested by Ezri and colleagues¹ that class zero be added to the Mallampati airway assessment scale² in order to describe "the ability to see any part of the epiglottis upon mouth opening and tongue protrusion."¹ The class zero airway has been demonstrated primarily in adults^1,3–5 with female predominance,¹ and has been associated with easy intubation,¹ difficult intubation,^3–5 and difficult mask ventilation.³ Difficult intubation and mask ventilation are most likely due to obstruction of the glottic aperture by the large and flaccid epiglottis during airway management.^3,4 Laryngoscopy, intubation, and mask ventilation in a child with a class zero airway may prove challenging given the relatively elongated and stiff epiglottis characteristic of the pediatric population. Alternatively, these characteristics of the pediatric epiglottis may facilitate management of a class zero airway in children compared to adults. To date, there has been one description of a class zero airway in a child (nine-year-old boy), which was associated with easy intubation as well as easy laryngeal mask airway insertion.⁶ We describe the occurrence of a class zero airway in a healthy six-year-old boy who was referred to his family physician (Dr. Caplan) by his dentist for assessment of an incidental lingual appendage. Examination of this patient’s oropharynx in the sitting position with a neutral head position, open mouth, protruded tongue, and without phonation, aptly revealed the epiglottis, consistent with a class zero airway (Figure). This boy was accordingly dismissed from his family physician’s office and has yet to present for an anesthetic. Nonetheless, the prevalence of a class zero airway in children is probably higher than the literature (or lack thereof) suggests, and formal evaluation of the pediatric class zero airway for predicted ease of laryngoscopy, intubation, and mask ventilation is awaited.

View larger version (98K): [in this window] [in a new window]   FIGURE Class zero airway in a six-year-old boy.

References

1 Ezri T, Warters RD, Szmuk P, 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.[Abstract/Free Full Text]

2 Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985; 32: 429–34.[Medline]

3 Fang B, Norris J. Class zero airway and laryngoscopy (Letter). Anesth Analg 2004; 98: 870–1.[Free Full Text]

4 Grover VK, Mahajan R, Tomar M. Class zero airway and laryngoscopy (Letter). Anesth Analg 2003; 96: 911.[Free Full Text]

5 Xie X, Au-Truong X, Klowden AJ, Joseph NJ, Ramez Salem M. Mallampati class "zero" (Letter). Anesth Analg 2002; 94: 1371.[Free Full Text]

6 Okamoto E, Sakuragi T, Sugi Y, Shono S, Higa K. Endotracheal intubation and a laryngeal mask airway in a child with Mallampati class zero airway (Letter). Anesth Analg 2004; 98: 557.[Free Full Text]

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