To the Editor: 

I read with interest the recent case published in ANESTHESIOLOGY titled “Intermittent Airway Obstruction in a Neonate” by Schwartz et al.  1The main purpose of the publication was to show images of the cystic supraglottic lesion responsible for airway compromise and the images before and after surgical management. However, I could not help but notice that the authors described the intubation as “easily accomplished with direct laryngoscopy.” They describe the mass involving not only the base of the tongue, but also the epiglottis and the glottis opening. The images show a Cormack-Lehane grade 3 view2that corresponds to a percentage of glottic opening (POGO) score of 0%,3a “restricted” or “difficult” view in the Cook classification (we do not know exactly because there is no mention whether the epiglottis could be lifted during direct laryngoscopy).4Usually these conditions are not conducive to “easy” laryngoscopy or intubation procedures. There are cases when one may predict and encounter difficult laryngoscopy and there is no difficulty performing the actual intubation (e.g. , blind intubation) and occasions when laryngoscopy is easy and the intubation difficult (e.g. , subglottic stenosis), but these cases are rare, and the usual occurrence is that if there is a limited laryngeal view, intubation requires multiple attempts, providers, and devices, and there is greater potential for complications; the procedure is far from being considered “easy” and in fact may well be impossible.

Schwartz AJ, Javia L, Stricker PA, Nadeau P, Nguyen C: Intermittent airway obstruction in a neonate. ANESTHESIOLOGY 2011; 115:630
Cormack RS: Cormack-Lehane classification revisited. Br J Anaesth 2010; 105:867–8
Ochroch EA, Hollander JE, Kush S, Shofer FS, Levitan RM: Assessment of laryngeal view: Percentage of glottic opening score vs  Cormack and Lehane grading. Can J Anaesth 1999; 46:987–90
Cook TM: A new practical classification of laryngeal view. Anaesthesia 2000; 55:274–9