“Originally there were three Mallampati grades; a fourth was added by Samsoon and Young.”—Pilkington et al.  1 

To the Editor:—  We read with interest the recent editorial commentary by Isono2referencing the article by Kodali et al.  3Isono states: “The Mallampati classification is a rough estimate of the tongue size relative to the oral cavity…. In addition to difficult tracheal intubation, Mallampati class 3 or 4 is an independent predictor for difficulty of mask ventilation during anesthesia induction and presence of obstructive sleep apnea.”2In contrast, Kodali et al.  state: “In the first study, we used the conventional Samsoon modification of the Mallampati score to evaluate airway changes.”3We believe that while Kodali et al.  correctly identify the Samsoon–Young modification of the Mallampati score, which changed the original 3-point scale of Mallampati to a 4-point scale,4,5the editorial comment represents the latest example of the Mallampati score being “lost in translation.”

Other examples of the confusion this change generated can easily be found. Farcon et al. ,6in their report on changing airway score during labor, state: “For this reason, a Mallampati evaluation of the airway with or without the Samsoon–Young additions is performed … on admission of the pregnant woman to hospital.” However, they then confuse the issue by stating: “A repeat airway evaluation … revealed marked edema of the lower pharynx giving rise to a Mallampati score of III–IV.” In contrast, Pilkington et al.  1(quoted above), in their study of airway changes in pregnancy, clearly noted the difference between the original Mallampati score out of 3 and the addition of a fourth grade by Samsoon and Young.

In chapter 21 of Shnider and Levinson’s Anesthesia for Obstetrics , Stackhouse and Bainton7appropriately outline both the original Mallampati classification and the score’s modification by Samsoon and Young. However, their figure 21.1 carries the confusing legend: “Mallampati classification. Pictorial classification of the pharyngeal structures as seen when conducting the examination.” Fortunately, the situation is redeemed by an acknowledgment that follows: “Adapted from Samsoon GLT, Young JRB …”

Malinow,8writing in Norris’s Obstetric Anesthesia , 2nd Edition, first cites Samsoon and Young’s retrospective review of “seven parturients who previously experienced failed intubation.” He then references the article by Rocke et al. ,9who “calculated the relative risk of difficulty at tracheal intubation versus  a Mallampati class 1 airway.” However, table 3, which lists “Relative risk of factors associated with difficulty at tracheal intubation as compared with an uncomplicated Mallampati class 1 evaluation,” includes as an “anatomic feature—Mallampati 4.” Yet Rocke et al.  clearly state: “We have therefore evaluated the Mallampati test as modified by Samsoon and Young in a large obstetric population undergoing cesarean section under general anesthesia.”9 

Watanabe and Handa’s10chapter titled “Difficult and Failed Intubation” in the Textbook of Obstetric Anesthesia  edited by Birnbach, Gatt, and Datta includes an illustration (fig. 32-1) of four upper airway views (class I–IV) said to originate from the original 1985 article by Mallampati et al.  4 

Similarly, Kuczkowski, Reisner, and Benumof’s11chapter, “The Difficult Airway: Risk, Prophylaxis, and Management,” in the latest edition of Chestnut’s Obstetric Anesthesia Principles and Practice  also includes an illustration (fig. 31-4) of four upper airway views (class I–IV) once again said to originate from the original 1985 article by Mallampati et al. 

In a recent review titled “Airway Problems in Pregnancy,” Munnur and Suresh12state that the Mallampati classification “evaluates the size of the tongue relative to the size of the oropharyngeal cavity. It is divided into four classes based on the oropharyngeal structures seen on opening the mouth:…; and class IV, only hard palate.” In addition, both Pilkington et al.  and Rocke et al.  are misquoted as having used the “Mallampati scores” to report on the incidence of “Mallampati class IV airways.”

In a later article, these same authors, joined by de Boisblanc,13offer a clearer text rendition of the modification of the original Mallampati score by Samsoon and Young. However, figure 1 illustrates four airway classes with the legend: “Difficulty of intubation based on Mallampati classification. Adapted from Mallampati SR: A clinical sign to predict difficult tracheal intubation: A prospective study. Can J Anaesth  1985; 32: 429.” It seems that Mallampati’s six coauthors were lost in translation too.

In a lighter vein, Doyle and Wilson provide a similar illustration (no mention of its origin) in a continuing medical education program*on management of the difficult airway published in Anesthesiology News .14 

In the interests of historical accuracy, we think it is important to clearly differentiate between the original 3/3 Mallampati score and 4/4 modification thereof published subsequently by Samsoon and Young. By so doing, the Mallampati score may emerge from its current situation of being “lost in translation” because of the confusion introduced by the Samsoon–Young modification and may thereby assume its proper and important place in the history and practice of anesthesia.

†Vanderbilt University School of Medicine, Nashville, Tennessee. john.downing@vanderbilt.edu

Pilkington S, Carli F, Dakin MJ, Romney M, De Witt KA, Doré CJ, Cormack RS: Increase in Mallampati score during pregnancy. Br J Anaesth 1995; 74:638–42
Isono S: Mallampati classification, an estimate of upper airway anatomical balance, can change rapidly during labor. Anesthesiology 2008; 108:347–9
Kodali B-S, Chandrasekhar S, Bulich LN, Topulos GP, Datta S: Airway changes during labor and delivery. Anesthesiology 2008; 108:357–62
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
Samsoon GLT, Young JRB: Difficult tracheal intubation: A retrospective study. Anaesthesia 1987; 42:487–90
Farcon EL, Kim MH, Marx GF: Changing Mallampati score during labor. Can J Anaesth 1994; 41:50–1
Stackhouse RA, Bainton CR: Difficult airway management, Shnider and Levinson’s Anesthesia for Obstetrics, 4th edition. Edited by Hughes SC, Levinson G, Rosen MA. Philadelphia, Lippincott Williams & Wilkins, 2001, pp 375–6Hughes SC, Levinson G, Rosen MA
Lippincott Williams & Wilkins
Malinow AM: General anesthesia for cesarean delivery, Obstetric Anesthesia, 2nd edition. Edited by Norris MC. Philadelphia, Lippincott Williams & Wilkins, 1999, pp 376–7Norris MC
Lippincott Williams & Wilkins
Rocke DA, Murray WB, Rout CC, Gouws E: Relative risk analysis of factors associated with difficult intubation in obstetric anesthesia. Anesthesiology 1992; 77:67–73
Watanabe S, Handa F: Difficult and failed intubation, Textbook of Obstetric Anesthesia. Edited by Birnbach DJ, Gatt SP, Datta S. Philadelphia, Churchill Livingstone, 2000, p 457Birnbach DJ, Gatt SP, Datta S
Churchill Livingstone
Kuczkowski KM, Reisner LS, Benumof JL: The difficult airway: Risk, prophylaxis, and management, Obstetric Anesthesia Principles and Practice, 3rd edition. Edited by Chestnut DH. Philadelphia, Elsevier Mosby, 2004, p 540Chestnut DH
Elsevier Mosby
Munnur U, Suresh MS: Airway problems in pregnancy. Crit Care Clin 2004; 20:617–42
Munnur U, de Boisblanc B, Suresh MS: Airway problems in pregnancy. Crit Care Med 2005; 33:s259–68
Doyle DJ, Wilson W: CME: Management of the difficult airway: Use of the laryngeal mask in three cases. Anesthesiol News 2006; 32:47–55