Mallampati and airway examination

5 min read Last updated April 8, 2026

Why you examine the airway

  • To predict difficulty with: mask ventilation, supraglottic airway (SGA) insertion, laryngoscopy/intubation, and front-of-neck access (FONA).
  • To choose the safest plan (Plan A/B/C/D) and ensure the right help and equipment are present.
  • To identify “can’t intubate, can’t oxygenate” (CICO) risk factors early and reduce surprises.
  • To document findings clearly so the whole team shares the same mental model.

Mallampati score (what it is and how to do it)

  • Mallampati is a bedside view of the mouth/throat that helps estimate how easy laryngoscopy might be (it is not a perfect test).
  • How to perform: patient sitting up, head neutral, mouth opened as wide as possible, tongue fully out, NO phonation (don’t say “ahh”). Use a good light.
  • Class I: soft palate, uvula, fauces and tonsillar pillars visible.
  • Class II: soft palate and uvula visible (pillars not fully).
  • Class III: soft palate visible, only base of uvula seen.
  • Class IV: only hard palate visible.
  • Higher class (III–IV) suggests more difficult laryngoscopy, but always interpret alongside other findings.

A practical airway exam: what to look at (quick routine)

  • Look: facial hair, obesity, facial/neck swelling, trauma, burns, stridor, voice change, work of breathing.
  • Mouth opening: aim for ≥3 finger breadths (inter-incisor distance). Limited opening predicts difficulty with laryngoscopy and SGA insertion.
  • Teeth: prominent incisors, loose teeth, dentures, caps/bridges (risk of damage/aspiration).
  • Mallampati: do correctly and record the class.
  • Jaw movement: can the lower incisors bite above the upper incisors? (upper lip bite test). Poor protrusion suggests difficult laryngoscopy.
  • Neck movement: can they extend at the atlanto-occipital joint? Reduced extension makes alignment harder.
  • Thyromental distance: roughly ≥6.5 cm (about 3 finger breadths) is reassuring; short distance suggests anterior larynx/difficulty.
  • Neck circumference: large neck (often >40 cm) increases risk of difficult mask ventilation and laryngoscopy.
  • Nasal patency if considering nasal oxygenation/nasal intubation (ask, look, and consider history of epistaxis).

Predicting difficulty: what matters for new starters

  • No single test is reliable—combine findings and err on the side of caution.
  • Difficult mask ventilation risk factors: obesity, beard, older age, edentulous, OSA, limited jaw protrusion, reduced neck mobility.
  • Difficult laryngoscopy/intubation risk factors: Mallampati III–IV, limited mouth opening, reduced neck extension, short thyromental distance, prominent incisors, large neck.
  • Difficult SGA insertion/ventilation: limited mouth opening, high airway pressures (obesity, lung disease), abnormal anatomy.
  • Potential difficult FONA: neck swelling, previous neck surgery/radiotherapy, inability to palpate landmarks, obesity—consider early senior help.

First-time scenarios: what to do with your findings

  • If airway looks straightforward: still have a backup (different blade, bougie, second-generation SGA) and check suction works.
  • If any concern: tell your supervisor early, optimise positioning, and plan for oxygenation first (pre-oxygenation, apnoeic oxygenation).
  • Positioning: aim for “sniffing” in most; in obesity use a head-up/ramped position so the ear canal is level with the sternal notch.
  • If aspiration risk: consider rapid sequence induction (RSI) with senior support; ensure suction, appropriate drugs, and a clear failed intubation plan.
  • If predicted difficult intubation but ventilation likely easy: consider starting with video laryngoscopy, use a bougie early, and keep attempts limited.
  • If predicted difficult ventilation and intubation: escalate early; consider awake techniques or regional/alternative anaesthesia where appropriate (senior decision).

How to document (simple and useful)

  • Record: Mallampati class, mouth opening, dentition, neck movement, thyromental distance (or “adequate”), jaw protrusion, and any concerns (OSA/obesity/stridor).
  • Write a brief plan: intended technique + backups (e.g., “VL first line; bougie; 2nd-gen SGA; call for help early”).
  • If difficulty encountered, document what worked (device, blade size, view, adjuncts) for future anaesthetics.
What does Mallampati actually predict?

Mainly difficulty with direct laryngoscopy (view at laryngoscopy). It is less reliable for predicting mask ventilation or SGA success, so combine with other tests.

How do I avoid getting the Mallampati wrong?

– Sit patient up, neutral head – Mouth wide open, tongue fully out – No phonation (don’t say “ahh”) – Use a light and look quickly before they tire

Is Mallampati III/IV an automatic ‘difficult airway’?

No. It increases risk, but many patients are still easy. Treat it as a warning sign and look for other risk factors before deciding your plan.

What is the quickest safe airway exam when you’re busy?

– Look (obesity/beard/stridor) – Mouth opening – Mallampati – Neck movement – Jaw protrusion – Dentition

What should I do if I find loose teeth or dentures?

– Identify and document – Remove dentures before induction (unless specifically advised otherwise) – Warn the patient about risk of dental injury – Be gentle with laryngoscopy and consider video laryngoscopy if prominent incisors

What’s the most important ‘first-time’ optimisation step?

Positioning and oxygenation: head-up/ramped when needed, good mask seal, pre-oxygenate properly, and use nasal oxygen during apnoea if appropriate.

When should I call for senior help early?

– Stridor/airway obstruction signs – Previous difficult airway or airway surgery/radiotherapy – Very limited mouth opening/neck movement – Multiple predictors of difficult mask ventilation and intubation – You feel unsure (that alone is a valid reason)

How many intubation attempts are reasonable?

Keep attempts limited and purposeful. If the first attempt is poor, change something (position/device/operator) and escalate early to avoid trauma and hypoxia.

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