Effects of posture, phonation and observer on Mallampati classification

We have studied the effects of phonation and posture on the Mallampati classification of view of the pharyngeal structures. Differences between observers were allowed for by the experimental design and log-linear modelling. Sixty-four patients were assessed on the ward, sitting upright, with and without phonation, by each of two observers. Another 64 patients were assessed without phonation, but both upright and supine, again by both observers. Phonation (the patient saying "Ah") produced a marked, systematic improvement of view; moving to the supine posture produced a small, systematic, non-significant worsening of the view. Differences between observers were non-systematic but substantial. About 25% of patients phonated spontaneously. It is recommended that anaesthetists make their own assessments of Mallampati classification, with the patient in either of the postures but always either with or without phonation, and thereby gradually "calibrate" their assessments against the degree of difficulty encountered in intubation.