Sitting Versus Supine Modified Mallampati Test for Predicting Difficult Airway: A Systematic Review and Meta-analysis

The modified Mallampati test is performed in the sitting position as part of airway evaluation to predict difficult airway. However, it is not feasible in patients unable to sit, and the accuracy in supine position remains unclear. This study compared the diagnostic performance of the modified Mallampati test between two positions.

We conducted a systematic review and meta-analysis of observational studies evaluating the modified Mallampati test in supine and sitting positions in the same patients. PubMed, Embase, Cochrane Database, and Web of Science were searched from inception to January 2026. The primary outcome was diagnostic accuracy of difficult laryngoscopy, defined as Cormack-Lehane grade ≥III. Pooled sensitivity and specificity were estimated using bivariate random-effects models. Meta-regression and likelihood ratio test were used to assess the effect of patient position.

Twenty studies involving 8261 patients were included. Pooled sensitivity and specificity for the sitting position were 0.661 (95% confidence interval [CI], 0.573-0.738) and 0.783 (95% CI, 0.684-0.858), respectively, and those for the supine position were 0.750 (95% CI, 0.617-0.849) and 0.705 (95% CI, 0.57-0.813), respectively. Summary receiver operating characteristic curves indicated substantial overlap. Meta-regression and likelihood ratio test indicated that patient position was a nonstatistically significant covariate for sensitivity or the false-positive rate.

The diagnostic accuracy of the modified Mallampati test for predicting difficult airway was not significantly associated with patient position. Supine assessment may be an alternative when upright assessment is not feasible as part of a multimodal airway assessment.