Users Online: 1794 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  
Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions | Subscribe | Contacts | Login 

RSACP wishes to inform that it shall be discontinuing the dispatch of print copy of JOACP to it's Life members. The print copy of JOACP will be posted only to those life members who send us a written confirmation for continuation of print copy.
Kindly email your affirmation for print copies to [email protected] preferably by 30th June 2019.


Table of Contents
Year : 2012  |  Volume : 28  |  Issue : 2  |  Page : 264-265

Mallampatti class 4 to class 1!!

1 Department of Anaesthesiology, Kasturba Medical College, Manipal, Manipal University, Bangalore, Karnataka, India
2 Narayana Hrudayalaya, Bangalore, Karnataka, India

Date of Web Publication11-Apr-2012

Correspondence Address:
Rohith Krishna
Department of Anaesthesiology, Kasturba Medical College, Manipal University, Manipal - 576104
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9185.94918

Rights and Permissions

How to cite this article:
Krishna R, Wali M, Nataraj MS, Shenoy T. Mallampatti class 4 to class 1!!. J Anaesthesiol Clin Pharmacol 2012;28:264-5

How to cite this URL:
Krishna R, Wali M, Nataraj MS, Shenoy T. Mallampatti class 4 to class 1!!. J Anaesthesiol Clin Pharmacol [serial online] 2012 [cited 2021 Apr 18];28:264-5. Available from:


A ranula is a retention cyst filled with mucus, occurring as a result of the blockage of a sublingual salivary gland or unnamed glands in the oral cavity. [1] Plunging ranulas associated with or without oral swellings can burrow into the submandibular, submental, and retropharyngeal spaces, lateral aspect of neck, and upper mediastinum. They are usually asymptomatic but rarely cause dysphagia and potential airway obstruction. [2],[3]

A 4-year-old boy presented with a history of swelling in the sublingual region gradually increasing in size since 3 years. The patient had difficulty in eating solid food, the mouth was always kept open, and there was excess salivation. On examination, a swelling measuring 5 × 4 cm was seen in the sublingual region extending more to the left side and pushing the tongue into the oral cavity and leaving the mouth open. Airway examination revealed the tongue almost covering the entire oral cavity making the uvula with palatal arch not visible and it graded as a Mallampatti class 4 airway The thyromental distance could not be measured correctly because the swelling was in the submandibular and submental regions. The child was apparently healthy with no respiratory distress and systemic disorders.

The child was scheduled for excision of the cyst. After premedication with atropine 0.4 mg and midazolam 1 mg intravenously (IV), through an IV cannula in situ, the child was shifted to the operating room. Standard monitors were connected and anesthesia was induced with thiopentone. Suxamethonium administered after confirming adequacy of ventilation. Oral tracheal intubation was planned as difficulty in visualization of vocal cords was anticipated. The vocal cords were not visible on direct laryngoscopy with help of a size 2 Macintosh (MAC) blade. As the blade was swept over the tongue, the tip of the blade could not be manipulated into the vallecula beyond the swelling. The tip of the blade could be manipulated beyond the swelling to visualize the posterior commissures of the cords, with an external laryngeal pressure, when an MAC 3 adult-sized blade was used. An uncuffed 5-mm ID endotracheal tube (ETT) with stylet was passed through the vocal cords with difficulty in the second attempt [Figure 1].
Figure 1: Lateral profile after oral intubation showing swelling in mandibular region

Click here to view

We decided to secure the ETT using the nasal route as there was concern of tube coming in surgical field and accidental tracheal extubation during surgical manipulation. Aspiration of the 50 ml of fluid from cyst was done. The swelling was reduced sufficiently in size [Figure 2]. Laryngoscopy was attempted with MAC 2 blade and this time the vocal cords were easily visible (Cormack and Lehanne grade 1) without any external manipulation. Nasal intubation was carried out easily with a 4.5-mm ID uncuffed ETT and the throat packed. Marsupialization of the cyst was done. Tracheal extubation was uneventful.
Figure 2: Aspiration of the cyst after intubation

Click here to view

Surgical management is preferred for most ranulas. Marsupialization is done preserving the sublingual gland and adjacent tissue. [4] Molar intubation or paraglossal techniques, requiring expertise, are advocated when standard laryngoscopy as a large tongue remains anterior to the blade due to a large infraoral swelling. [5]

Use of an MAC 3 adult blade in young children in these situations is required to go beyond the swelling up to the base of the tongue into the vallecula and visualize the epiglottis and then the glottis. In close consultation with the surgical colleague, the feasibility of aspiration of the cystic lesions should be considered, if does not interfere with the plane of dissection. For safe airway management in selective cystic lesions, particularly in the absence of availability of difficult intubation aids, the cyst can be aspirated before tracheal intubation.

  References Top

1.Baurmash HD. Mucoceles and ranulas. J Oral Maxillofac Surg 2003;61:369-78.  Back to cited text no. 1
2.Horiguchi H, Kakuta S, Nagumo S. Bilateral plunging ranula. A case report. Int J Oral Maxillofac Surg 1995;24:174-5.  Back to cited text no. 2
3.Shelley MJ, Yeung KH, Bowley NB, Sneddon KJ. A rare case of an extensive plunging ranula : D0 iscussion of imaging, diagnosis, and management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:743-6.  Back to cited text no. 3
4.Yoshimura Y, Obara S, Kondoh T, Naitoh SI, Schow SR. A comparison of three methods used for treatment of ranula. J Oral Maxillofac Surg 1995;53:280-3.  Back to cited text no. 4
5.Potdar M, Patel RD, Dewoolkar LV. Molar Intubation for Intra Oral Swellings : O0 ur Experience. Indian J Anaesth 2008;52:861.  Back to cited text no. 5
  Medknow Journal  


  [Figure 1], [Figure 2]

This article has been cited by
1 Anaesthetic management in a case of large plunging ranula with difficult airway: A case report
Surendra Kumar Sethi,Neena Jain,Arvind Khare,Veena Patodi
Egyptian Journal of Anaesthesia. 2016;
[Pubmed] | [DOI]
2 Anaesthetic management in a case of huge plunging ranula
Sarbari Swaika,Jagabandhu Sheet,Anamitra Mandal,Swapnadeep Sengupta,Debaleena Jana,Sudakshina Mukherji
Anesthesia: Essays and Researches. 2014; 8(1): 114
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
   Article Figures

 Article Access Statistics
    PDF Downloaded328    
    Comments [Add]    
    Cited by others 2    

Recommend this journal