European Journal of Anaesthesiology 2008; 25: 681–684 r 2008 Copyright European Society of Anaesthesiology doi:10.1017/S0265021508004110 Original Article Does left molar approach to laryngoscopy make difficult intubation easier than the conventional midline approach? N. Bozdogan, M. Sener, A. Bilen, A. Turkoz, A. Donmez, G. Arslan Baskent University Faculty of Medicine, Department of Anesthesiology, Ankara, Turkey Summary Background and objective: It has been reported that the left molar approach of laryngoscopy can make difficult intubation easier. The aim of this study was to investigate whether left molar approach to laryngoscopy provided a better laryngeal view in cases of unexpected difficult intubation. Methods: Following the approval of local Ethics Committee and written informed consent from the patients, out of 1386 patients who underwent general anaesthesia for surgery, 20 patients who could be ventilated by face mask but could not be intubated with conventional midline approach on the first attempt were included in the study. Those 20 patients, who had Grade III-IV laryngeal views on laryngoscopy by conventional midline approach, were subjected to left molar laryngo- scopy, and their laryngeal views were evaluated. The external laryngeal compression was routinely used to improve the laryngeal view. When endotracheal intubation failed by left molar laryngoscopy, we performed the conventional midline approach again. All data were recorded. Results: Of the 20 patients studied, 18 had a Grade III laryngeal view and two had a Grade IV laryngeal view. Eighteen of them had a better laryngeal view with left molar laryngoscopy. Eleven of the 20 patients underwent successful intubation with the left molar laryngoscopy, which provided a significantly better laryngeal view and success rate of tracheal intubation than did the conventional midline approach (P , 0.01 and P , 0.01, respectively). Conclusions: Left molar laryngoscopy can make unexpected difficult intubation easier and should be attempted in cases of difficult intubation. Keywords: INTUBATION INTRATRACHEAL, technique; LARYNGOSCOPES, Macintosh; LARYNX. Introduction Unexpected difficult laryngoscopy or intubation increases morbidity and mortality in anaesthesia practice [1]. In some studies, the frequency of dif- ficult laryngoscopy or intubation varied from 1% to 18%, and intubation fails in 0.05% to 0.35% of patients who have difficult laryngoscopy [2,3]. Depending on the laryngeal views required and the definition of ‘difficult intubation’ applied, the incidence of difficult laryngoscopy varies with the pressure application on the larynx and with the use of different blades and techniques [4–7]. There are various methods of predicting difficult intubation, such as the Mallampati classification [8], head–neck motility [4], the measurement of sternomental and thyromental distances [1,2] and the results of the Wilson risk sum [9]. However, those methods may not be sufficient to determine the risk of difficult intubation, and unexpected difficulties in intubation may occur [2]. Recently, left molar approach of laryngoscopy has been reported to make difficult intubation easier [10–13]. We therefore aimed to investigate whether left molar approach of laryngoscopy provided a better laryngeal view than conventional midline approach and made intubation easier for unexpected difficult intubation. Correspondence to: Nesrin Bozdogan, Anesteziyoloji ve Reanimasyon AD, Baskent Universitesi Adana Seyhan Hastanesi, Baraj yolu 1. durak no: 37, 01140 Seyhan/Adana, Turkey. E-mail: nesrinbozdogan@yahoo.com; Tel: 190 322 4586868, Ext. 1226; Fax: 190 322 4592622 Accepted for publication 2 March 2008 EJA 4849 First published online 11 April 2008