Letters to the Editor
To the Editor:
Forceful, 3-cm anterior elevation (AE) with a conventional curved blade 4 and optimal external laryngeal manipulation  resulted in failure to expose the posterior commissure of glottis in two anesthetized patients with anterior larynx. The first attempt at endotracheal intubation failed in both patients.
Preoperatively, the airway of Patient 1 was evaluated as Mallampati class 4 [2,3] with limited neck extension (20[degree sign]). Patient 2 presented for resection of cervical tumor causing left anterior laryngeal displacement (thyroid prominence palpable 3 cm left-to-midline).
The second endotracheal intubation attempt was successful because we used a modified Macintosh blade (MMB) 4 carrying two 10 Foley catheters (Figure 1). In Patient 1, the MMB was advanced deep into vallecula, right catheter-balloon inflation with 2 mL of air exposed the arytenoids, and MMB-AE of 1.5 cm revealed the posterior half of glottis. In Patient 2, the MMB tip was placed above the displaced epiglottis, left catheter balloon inflation with 2 mL of air exposed the posterior half of glottis, and MMB-AE of 0.5 cm revealed the entire laryngeal aperture.
We conclude that adequate contact between balloon upper surface and structures connected to the epiglottis (base of tongue and hyoid bone) was established by balloon inflation. Consequently, lifting of the epiglottis by MMB-AE and exposure of the glottis were facilitated.
Spyros D. Mentzelopoulos, MD, DEAA(P1)
Marina V. Tsitsika, MD
Evangelia A. Karamichali, MD, PhD
Department of Anesthesia; Evangelismos General Hospital; Athens, Greece
1. Benumof JL, Cooper SD. Quantitative improvement in laryngoscopic view by optimal external laryngeal manipulation. J Clin Anesth 1996;8:136-40.
2. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can J Anaesth 1985;32:429-34.
3. Samsoon GLT, Young JRB. Difficult tracheal intubation: a retrospective study. Anaesthesia 1987;42:487 90.