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Letters to the Editor: Letters & Announcements

The Upper Lip Bite Test to Predict Difficult Intubation

Tong, Jeffrey L. FRCA; Gait, Andrea J. FRCA

Editor(s): Saidman, Lawrence

Author Information
doi: 10.1213/ane.0b013e3181619740
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To the Editor:

In a recent report, the upper lip bite test was used to correctly predict an easy intubation in a patient with Cushing's and Nelson's syndromes.1

Their article describes the oropharyngeal image in Figure 2 as a Class IV airway, using the Samsoon and Young modification of Mallampati classification. The published image is incorrect, as the lower lip is still visible because the tongue has not been maximally protruded.2 Bedside airway screening tests must be reliable and quick to perform. The use of single screening tests for difficult intubation3 is associated with low Positive Predictive Value (the proportion of cases predicted to be difficult, who actually were difficult), but it is crucial that whichever assessment is used, it must be performed correctly.

Finally, forward movement of the mandible according to the position of the lower incisors in relation to the upper incisors, has previously been published in this Journal.4,5

Jeffrey L. Tong, FRCA

Academic Department of Military Anaesthesia

Royal Centre for Defence Medicine

Birmingham UK

[email protected]

Andrea J. Gait, FRCA

Department of Anaesthesia

Birmingham Heartlands Hospital

Birmingham UK


1. Khan ZH, Gharabaghian M, Ferozeh N, 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
2. Samsoon GLT, Young JRB. Difficult tracheal intubation: a retrospective study. Anaesthesia 1987;42:487–90
3. Eberhart LH, Arndt C, Cierpka T, Schwanekamp J, Wulf H, Putzke C. The reliability and validity of the upper lip bite test compared with the Mallampati classification to predict difficult laryngoscopy: an external prospective evaluation. Anesth Analg 2005;101:284–9
4. Brechner VL. Unusual problems in tracheal intubation – 1. Anesth Analg 1968; 47:362–73
5. Block C, Brechner VL. Unusual problems in airway management – 2. Anesth Analg 1971;50:114–23
6. 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
© 2008 International Anesthesia Research Society