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Table of Contents
Year : 2018  |  Volume : 34  |  Issue : 2  |  Page : 247-248

Head elevation beyond sniffing position – An aid to airway management

Department of Anesthesiology and Critical Care, University College of Medical Sciences and GTB Hospital, New Delhi, India

Date of Web Publication16-Jul-2018

Correspondence Address:
Medha Mohta
28-B, Pocket-C, SFS Flats Mayur Vihar Phase-III, Delhi-110096
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joacp.JOACP_173_17

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How to cite this article:
Mohta M. Head elevation beyond sniffing position – An aid to airway management. J Anaesthesiol Clin Pharmacol 2018;34:247-8

How to cite this URL:
Mohta M. Head elevation beyond sniffing position – An aid to airway management. J Anaesthesiol Clin Pharmacol [serial online] 2018 [cited 2020 May 25];34:247-8. Available from:

Direct laryngoscopy and tracheal intubation is one of the basic and the most important skills in anesthetic practice. This requires proper positioning of head and neck to adequately visualize the glottis and easily negotiate the tracheal tube through the glottic opening. The position traditionally recommended and taught to all learners of airway management is the “sniffing position” (SP). This involves neck flexion (head elevation) by putting a pillow under the head and then extending the head at atlanto-occipital joint. The SP is thought to help by allowing the line of vision to fall straight on the laryngeal inlet by aligning oral, pharyngeal, and laryngeal axes. This is the three-axes alignment theory (TAAT) that describes alignment of pharyngeal and laryngeal axes by flexion of neck and alignment of oral axis with the other two axes by extension of the head.[1]

After more than 50 years of formulation and acceptance of the TAAT theory, concerns regarding its correctness were raised by Adnet et al.[2] This started a debate on the usefulness of SP and various workers began exploring alternative positions for laryngoscopy and tracheal intubation. It was argued that SP does not bring the three axes into alignment.[2] However, this argument was opposed by others who suggested that SP brings these axes as close to each other as possible and then laryngoscopy does the rest of the job, completing the alignment.[3]

In search of a better alternative to SP, many studies have been conducted comparing SP with simple head extension (without head elevation). Most of these studies have confirmed the superiority of SP over simple head extension.[4],[5] Thus, it has become clear that head elevation or neck flexion improves the glottic view. However, how much elevation of head provides the best view is not yet clear. So there has been a surge of interest in exploring the role of further head elevation, beyond that required for SP, in improving the laryngoscopic view.[6],[7],[8] Most of the studies have reported better views with further head elevation beyond SP. Recently, Orbany et al. examined the laryngeal view in three different positions using inflatable pillows.[8] The positions studied were head extension with no head elevation, 6 cm head elevation (sniffing position), and 10 cm head elevation (elevated sniffing position). They found decrease in the incidence of difficult laryngoscopy from 8.38% without head elevation to 2.39% in SP and 1.19% in elevated SP. Thus, SP improved the laryngoscopic view but elevated SP further improved the view in most cases. Elevated SP did not worsen the view in any patient. Head elevation is thought to help by moving the glottis posteriorly, thus compensating for its anterior displacement during head extension; and probably resulting in better alignment of the three axes.[9] Moreover, head elevation allows more extension at atlanto-occipital joint by increasing range of motion.[10]

In the previous issue of JOACP, Gudivada et al. have compared the glottic view as well as intubating conditions with SP and further head elevation.[11] Their results are encouraging as they have demonstrated further head elevation position to be better than standard SP with respect to both these parameters. The strengths of this study are assessment of intubating conditions in addition to laryngoscopic view and ensuring appropriate SP. The SP was confirmed by bringing external auditory meatus and sternal notch at the same horizontal level and a 1.5-inch cushion was added to achieve further head elevation. Although glottic view improved in many patients, one patient in this study showed worsening of Cormack-Lehane grade by 1. Moreover, patients with difficult airways were excluded. Hence the results may not be applicable to these patients.

Thus, the study by Gudivada et al. adds to the limited evidence available in the literature on the role of head elevation beyond the standard SP in airway management. However, further research is indicated to confirm the advantages of this position in patients with anticipated difficult laryngoscopy and intubation. It would also be interesting to know the degree of alignment of oral, pharyngeal, and laryngeal axes with head elevation beyond SP using radiographic imaging.

  References Top

Bannister FB, Macbeth RG. Direct laryngoscopy and tracheal intubation. Lancet 1944;2:651-4.  Back to cited text no. 1
Adnet F, Borron SW, Lapostolle F, Lapandry C. The three axis alignment theory and the “sniffing position”: Perpetuation of an anatomic myth? Anesthesiology 1999;91:1964-5.  Back to cited text no. 2
Candido KD, Ghaleb AH, Saatee S, Khorasani A. Reevaluating the “Cornerstone of Training in Anesthesiology.” Anesthesiology 2001;95:1043-4.  Back to cited text no. 3
Prakash S, Rapsang AG, Mahajan S, Bhattacharjee S, Singh R, Gogia AR. Comparative evaluation of the sniffing position with simple head extension for laryngoscopic view and intubation difficulty in adults undergoing elective surgery. Anesthesiol Res Pract 2011;2011:297913.  Back to cited text no. 4
Chauhan S, Shende S, Shidhaye RV. Evaluation of laryngoscopic view, intubation difficulty and sympathetic response during direct laryngoscopy in sniffing position versus simple head extension: A clinical comparative study. Int J Med Res Rev 2016;4:1531-7.  Back to cited text no. 5
Schmitt HJ, Mang H. Head and neck elevation beyond the sniffing position improves laryngeal view in cases of difficult direct laryngoscopy. J Clin Anesth 2002;14:335-8.  Back to cited text no. 6
Levitan RM, Mechem CC, Ochroch EA, Shofer FS, Hollander JE. Head-elevated laryngoscopy position: Improving laryngeal exposure during laryngoscopy by increasing head elevation. Ann Emerg Med 2003;41:322-30.  Back to cited text no. 7
El-Orbany MI, Getachew YB, Joseph NJ, Salem MR, Friedman M. Head elevation improves laryngeal exposure with direct laryngoscopy. J Clin Anesth 2015;27:153-8.  Back to cited text no. 8
Hochman II, Zeitels SM, Heaton JT. Analysis of the forces and position required for direct laryngoscopic exposure of the anterior vocal folds. Ann Otol Rhinol Laryngol 1999;108:715-24.  Back to cited text no. 9
Takenaka I, Aoyama K, Iwagaki T, Ishimura H, Kadoya T. The sniffing position provides greater occipito-atlanto-axial angulation than simple head extension: A radiological study. Can J Anaesth 2007;54:129-33.  Back to cited text no. 10
Gudivada KK, Jonnavithula N, Pasupuleti SL, Apparasu CP, Ayya SS, Ramachandran G. Comparison of ease of intubation in sniffing position and further neck flexion. J Anaesthesiol Clin Pharmacol 2017;33:342-7  Back to cited text no. 11


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