Austin Korczak

Mallampati Scoring and Its

Relation to Obstructive
Sleep Apnea

Biology

April 27, 2017

Honors Program
Abstract: According to the American Sleep Apnea Association potentially 80% of moderate to severe cases of
Obstructive Sleep Apnea (OSA) go undiagnosed with even optimistic estimates stating that at least 22 million
Americans are afflicted by the disorder.9 These numbers are expected to continue to increase due to the rising
rates of obesity in America.30 As a result, reliable criteria that can help physicians accurately predict the
presence of an underlying sleep disorder, whose symptoms are masked during the day, is highly sought after.
The objective of this research is to begin defining these criteria via a literature review of articles that evaluate
the correlation of the Mallampati Scoring System (MSS), a frequently cited tool with promise in predicting
OSA, with other factors that have been established as predictors of OSA. These factors of interest include
Body Mass Index (BMI), neck circumference (NC), and the Apnea-hypopnea Index.
Introduction:
The MSS is a common non-invasive pre-surgical examination performed to estimate difficulty of
intubation. Insertion of cameras or supportive breathing devices into the nose and oropharynx is frequently a
necessity in emergency medicine in order to compensate for diseases that target the functionality of
respiration or the digestive tract, as a result mallampati scoring (MS) is used to help tailor anesthesia or pain-
killer to each patient during surgery to avoid potential complications. An MS is calculated while a patient is
awake and begins by the patient sticking out their tongue and the physician subsequently estimating how
much the tongue obstructs certain soft tissues within the throat, including the uvula, the faucial pillars, and
soft palate. Scores can range from 1-4, with 1 being the least severe and having full visualization of the base
of the uvula, and 4 being the most severe, with only the hard palate visible. This score can be obtained in less
than 15 seconds by a physician with no tools or prior preparation.4

Figure 1 Above depicts the four possible classes a Mallampati Score organizes patients into. Class 1 is
the least severe with clear visualization of the uvula above the tongue while Class 4 is the most severe
with its complete obscurement.6 The higher the MS, the more difficult the intubation.

Outside of MS’s typical usage in surgical settings, general care practitioners are often unaware of the
fact that it has potential in assisting in the diagnosis of Obstructive Sleep Apnea (OSA) patients.3, 7
Failure to recognize OSA arises due to difficulty of identifying symptoms in sleep breathing disorders
when the patient is conscious in combination with the patient themselves often being unaware of those
symptoms in the first place.

1 MALLAMPATI SCORING AND ITS RELATION TO OBSTRUCTIVE SLEEP APNEA, 2017

 Before delving into MSS and its potential significance in helping recognize OSA, familiarity with the
sleep cycle is necessary to understand the pathology of sleep breathing disorders. Below is a depiction of the
sleep cycle and the length of each stage exhibited by Figure 2 below:

Figure 2 Illustrates the stages of the sleep cycle with the X-axis detailing time elapsed in the
course of a night and the Y-axis showing the 5 stages of sleep and how easily awoken we are
from these stages.17

The sleep cycle is divided into 5 stages, each stage characterized by brain waves and muscle movement
that are monitored in a polysomnography (an overnight sleep study) via electrodes connected to the brain and
many muscles of the body. Sleep begins at stage 1 and will steadily progress to REM over the course of
roughly 90 minutes. After the completion of the REM stage the body reverses the process, lapsing back into
stages 4, 3, 2, and finally 1, which accounts for a whole sleep cycle lasting around 3 hours as illustrated in
Figure 1 above. Only the first 5 minutes of sleep is spent in the first stage, which represents the gap between
wakefulness and falling asleep. During stage 1 brain waves slow to produce theta waves in which awareness
of ones’ surroundings is lost but one remains easily awakened.13 Stage 2 lasts 10 to 25 minutes and accounts
for approximately 50% of our nightly sleep. It is characterized by spindle waves representing bursts of mental
activity occurring between large, slow waves during which heart rate and breathing slow.13 Stages 3 and 4 are
the beginning of “deep sleep” where large and slow brain waves, termed delta waves, are present. During
these stages the brain releases growth hormone to stimulate muscle repair and tissue growth.13,16 Children
and young adults spend about 20% of rest in this deep sleep, however as we age less and less of that time
constitutes deep sleep until by age 60 it is only 10%.13,16 Finally once REM begins the brain becomes highly
active while the body, aside from the eyes, is largely paralyzed. It is hypothesized in REM that the brain not
only eliminates unnecessary information, but commits to memory information accumulated throughout the
day.13 Each subsequent REM stage overnight will last longer than the previous and constitutes about 25% of
sleep in young adults and remains relatively unchanged as we age. 13 Deprivation of this stage of sleep heavily
impacts cognitive function and is shown to consist of a larger proportion of an individual’s sleep cycle if they
2 MALLAMPATI SCORING AND ITS RELATION TO OBSTRUCTIVE SLEEP APNEA, 2017
have a sleep deficit as well as lapsing into it more quickly.
This understanding of the sleep cycle lays the groundwork for understanding the pathophysiology of
OSA. As an individual predisposed toward OSA lapses into the deep stages of sleep, their anatomically
constricted airway, usually due to an enlarged tongue or shortened jaw, can ultimately lead to partial
obstruction of the airway and a phenomenon, known as snoring arises as demonstrated by Figure 3 below:

Figure 3: Demonstrates the obstruction of the airway via the tongue and how gravity can
exacerbate it if we sleep on our backs.24 It is important to recognize that a predisposition
toward OSA is as much an anatomical predisposition as it is due unhealthy lifestyle.

Over time the continuous vibrations caused by snoring can lead to desensitization of the soft tissues to
neuronal signaling around the pharynx, making them more resistant to stimulation, which ultimately leads to
concerns such as inadequate dilation of the pharynx and a total obstruction of the airway (cessation of
breathing) for a minimum of 10 seconds. This is referred to as an apnea, and mild OSA is diagnosed in
individuals with a minimum of 5 apneas over the course of an hour alongside a symptom such as day time
sleepiness or snoring.15 The Apnea-Hypopnea Index or AHI is a measurement of these apneas that take course
over an hour. Severity of an individual’s OSA is naturally correlated to their AHI calculated during a
polysomnography and provides the basis of OSA diagnosis. When unhealthy weight gain occurs in tandem
with a family history of OSA, (indicative of the presence of predisposing anatomical features including a
shortened neck, enlarged tongue, and retrognathia) OSA is more likely to result.
As BMI increases in an individual the proportion of fat in an individual’s tongue near the oropharynx
rises ultimately leading to greater likelihood of constriction of the pharynx.25 Figure 4 shown below will help
put this into perspective:

3 MALLAMPATI SCORING AND ITS RELATION TO OBSTRUCTIVE SLEEP APNEA, 2017

 Figure 4: Shows the physiologic changes that occur around the throat due to increasing BMI
and neck circumference, both of which are frequently cited predictors of OSA.26

Respiratory disorders such as OSA are generally far more common in men than women in part due to
how weight gain is exhibited differently between the genders.20 As men gain weight, extra adipose tissue is
synthesized around the neck and abdominal region, whereas in women, extra weight is directed toward the
lower extremities and buttocks.19 This gain in weight around the neck region becomes a problem for males
because two bulbs of fat surrounding the pharynx known as the pharyngeal fat pads will expand in size and as
a result constrict the pharynx. Furthermore, the weight gain on the abdomen necessitates extra force needed
in order for the diaphragm to expand during respiration and the pharynx to dilate. 19
In the event of an apnea, the need for oxygen rises due to the presence of an obstruction and burst of
cortisol is released awakening the patient and allowing for inhalation but at the cost of being deprived of REM
sleep continuously throughout the night.14 As an individual becomes sleep deprived, stress hormones begin to
rise in the blood stream these people will become chronically fatigued, leading to a sedentary lifestyle and a
greater likelihood of secondary cardiovascular disorders and a chronic rise blood pressure. 1 Due to OSA
patient’s unawareness of their symptoms they oftentimes acclimate to their chronic fatigue and live their lives
half-functional both cognitively and physically. As a result, those individuals with severe OSA may find that
resting on their side rather than in a supine position can help alleviate their symptoms as gravity no longer
acts to push the tongue onto the back of the pharynx.
Though the symptoms may not be obvious, OSA negatively impacts the patient in a multitude of ways
including chronic day time sleepiness, heightened probability for depression, and a great number of
cardiovascular maladies such as chronic high blood pressure or coronary artery disease may arise. 8 In
addition, OSA patients are also far more likely to be involved in car crashes or be unemployed for falling asleep
on the job.
Treatment of OSA is dependent on the severity of it with the most severe cases being treated via
continuous positive airway pressure (CPAP), a ventilator mask worn throughout the night. Less severe cases
are typically treated either through oral appliances, weight loss, or sleeping on one’s side. Although weight
loss has been shown to be the most effective treatment against respiratory disturbances, chronic OSA and the
4 MALLAMPATI SCORING AND ITS RELATION TO OBSTRUCTIVE SLEEP APNEA, 2017
subsequent deprivation of REM leads to physiologic changes in the body preventing it from benefitting from
exercise as healthy individuals would due to lack of energy. With a working understanding of OSA and MSS,
let’s have a look at the methods employed in this study.
OSA is conclusively diagnosed with a polysomnography, an overnight study at a sleep clinic where an
individuals’ breathing and sleep cycle are closely monitored. Due to the procedure being inconvenient and
time consuming an easily administered and noninvasive procedure is highly sought after as shown by a
statement from Gonzales: “A single instrument that accounts for excessive daytime sleepiness, as identified by
the Epworth Sleepiness Scale, snoring and high-risk characteristics, as recognized by the Berlin Sleep
Questionnaire, and anatomical features of the oropharynx, as delineated by the MSS, does not yet exist.”4 MS
and its association with factors that are correlated with a heightened predisposition toward OSA and its
relative severity could play an important role in bridging the gap between patient and physician understanding
of an undiagnosed sleep disorder as well as establish OSA status early on. In other words, should these factors
be reviewed in conjunction with a MS during a physical examination, it could help the physician gauge
whether follow up at a sleep clinic is appropriate for the patient. This is the biggest obstacle to be overcome
in order to curtail the degree of undiagnosed OSA cases. Examples of these factors that are kept under careful
scrutiny for all patients with OSA include Body Mass Index (BMI)5, NC28, and AHI.9 This study is intended to
begin defining criteria that are commonly demonstrated in patients with OSA so guidelines can be created to
reliably and accurately predict underlying OSA disorders.
Methods:
Limited data can be found in the MSS correlation with these factors that are linked to severity and
degree of predisposition a patient might have toward OSA. One such study by Johns that does investigate the
usefulness of MS came to this conclusion: “Mallampati Scoring System (MSS) instruments have independently
demonstrated clinical usefulness in identifying symptomology associated with high probability OSA.” 19 As data
such as this continues to accumulate about MS and its associations with OSA additional investigation becomes
more warranted, clarifying how MS, if not as an independent predictor of MS, could be used as a predictor
alongside other OSA predictors.
In order to establish these predictors as potential criteria in identifying OSA, a literature review of
articles addressing the association between MS to factors that are predictive of OSA as well as to OSA itself
were investigated. Factors that have shown promise include AHI, Body-Mass Index, and/or neck
circumference. MS and its association with AHI showcases how with increasing MS, increasing severity of OSA
is likely. Neck circumference and BMI correlations to MS begin to define how MS, NC, and BMI constitute
predictive diagnostic criteria to gauge likelihood of underlying OSA. Each P value isolated in a minimum 95%
confidence interval that establishes or does not establish a relation between MSS and these factors will be
mentioned. Should an adequate number of studies isolate a positive correlation between the MSS and OSA
predictors then this data would provide incentive to further investigate MS via its temporary incorporation
into a patient’s medical history to formally define criteria by which to reliably predict OSA without the use of
questionnaires such as the Epworth Sleepiness Scale or Berlin Questionnaires.

5 MALLAMPATI SCORING AND ITS RELATION TO OBSTRUCTIVE SLEEP APNEA, 2017

Results:
The Liistro study conducted a complete physical examination on 220 patients and compiled
measurements of MS, NC, height, weight, and AHI. Their findings indicate that MS in patients with nasal
obstruction, a common occurrence among OSA patients, were correlated with AHI, Body Mass Index, NC.5
Those patients with an MS of 3 or 4 were 1.95 times more likely to be at risk for OSA and those with nasal
obstruction were 2.45 times more likely. However no reliable correlation was established between MS and
OSAS in patients that did not possess a nasal obstruction as demonstrated by Figure 5:

Figure 5: Demonstrates the Liistro studies correlation between MS and AHI. The top
graph (a) is the population of patients without nasal obstruction while (b) below is the
population of patients with nasal obstruction.5

The group with OSA had, on average, 4.6 kg x m2 BMI, 3.1 cm NC, and 34.2 AHI greater than the group
without.5 Ultimately, they found; “simple and rapid elements such as the determination of MS and the
estimation of nasal permeability are useful for the clinical examination of the patients suspected of
obstructive sleep apnea syndrome.”5 This study is useful to demonstrate that as BMI, NC, and AHI rise, one
would expect an individual’s predisposition for OSA may rise.
Gonzalez conducted a study on 70 obese and 61 non-obese patients. He and colleagues hypothesized
that a history of OSA, high MS, increased age, male gender, short neck, and abnormal upper teeth were all
predictors of difficulty of intubation. Their findings showed that BMI, NC, and MS among their investigated
factors were determined to be correlated, with statistical significance (p<.05), to difficulty of intubation (MS).
NC showed as odds ratio of 1.373 and p=0.0012 while BMI was shown to have an odds ratio of 1.066 with
p=0.0497 by comparison to MS. Although the odds ratio of BMI was not strongly positive and OSA in the study
was evaluated only clinically and not via a polysomnography, this study establishes an association of MS, NC
and to a small degree, BMI, with difficulty of intubation, a variable closely linked to severity of OSA. 28
A study conducted by Hiremath found that; “difficult tracheal intubation (measured via MS) was
associated strongly with OSA.”12 They investigated 15 patients and separated their population into two groups

6 MALLAMPATI SCORING AND ITS RELATION TO OBSTRUCTIVE SLEEP APNEA, 2017

based on their AHI. Among the 8 patients with OSA (AHI >10), they found on average that MS was 1.1 points
greater and NC was 2.7 cm greater, with P<0.01, and P<0.05 respectively. Showing, much like the Liistro study,
a positive correlation between MS, AHI, and NC, with an exception to BMI, which was similar among the two
populations.12
Ahn and colleagues isolated a correlation between MS and AHI shown by their calculation of a
spearman coefficient (Rs); Rs=.295 with a p=0.018. Furthermore a “strong positive correlation” between BMI
and AHI was isolated with an Rs=.474 and p<0.001. Correlations between MS and NC were not evaluated in
the study.21 Among their conclusions was that “tongue volume is correlated with obesity, and OSA patients
with higher BMI are likely to have greater tongue volume.”21 This study is relevant in that it establishes a
correlation between MS, OSA, and BMI. However when comparing the two populations of OSA patients with
non-OSA patients, MS was found to increase by only .3 points and concluded it was not statistically signficant,
possibly owing to the fact that the intent of the study was not to establish a correlation between MS and OSA,
but tongue volume and OSA.
In the Kumar investigation, 158 patients were evaluated, of which 90 had OSA and all were tested for
AHI, MS, and tonsillar size.22 They stated among their significant findings that “for every point increase in MS,
the odds ratio of having OSA increased 6.75-fold, p<0.01.” Neither NC nor BMI were investigated in the study.
They found, “a significant correlation was found between MS, tonsillar size, and AHI.” The study not only
established MS as an independent predictor, but also showed a relationship between MS and AHI. A sample of
their data demonstrating this association can be seen below in Figure 6:

Figure 6: Shown are the results of the Kumar experiment wherein they measured (from left to
right on the X-axis) Mallampati score in the sitting position, in the supine position, and tonsillar
size. Observe the positive correlation as MS score increases on the x axis and AHI rises on the
y-axis for mallampati scoring in the supine position.22

7 MALLAMPATI SCORING AND ITS RELATION TO OBSTRUCTIVE SLEEP APNEA, 2017

 Similar to other studies, an investigation conducted by Kim and colleagues divided a population of
patients into an obese group (N=123) and a non-obese group (N=125) in an endeavor to show differences in
difficulty of intubation. Data showed that over double the number of individuals with a high MS of 3 to 4
resided in the obese group. Furthermore, on average NC was 4.4 cm greater and BMI was 6.4 kg x m2 greater
in the obese group.29 This data showcases how with increasing NC and BMI, MS is also predicted to rise.
However, the data in this study was not collected to establish a correlation to OSA and aid in its diagnosis.
A study by Nuckton and colleagues aimed to establish MS as an independent predictor of OSA. They
found among their findings that “for every 1 point increase in MS, the odds of having OSA increased by more
than 2-fold”. Additionally, NC was also investigated and found independently associated with OSA. These
relationships were established via odds ratios with MS to OSA being 2.5 per 1 point increase and NC to OSA
being 2.0 per 2.5 cm increase. Although not a strong association, BMI was found associated to OSA with an
odds ratio of 1.5 per 5-kg/m2 increase. Odds ratios of MS to AHI >10 was determined to have an odds ratio of
1.8. The Nuckton study is frequently cited in articles relating to the reliability of MS as it was shown to be a
reliable independent predictor of OSA. More reliable correlations were found between MS, AHI, OSA, and NC,
and to less significance, BMI.7
Finally, a study conducted by Hukins included 953 patients in his analysis. Among his findings included
“a statistically significant relationship between the independent variable of MS and the dependent variable of
AHI (Rs=0.13) but MS explained only 1.7% of the variability in AHI.” A correlation between AHI and BMI was
additionally isolated with an Rs=.25. His findings also showed that a Mallampati class of IV was only 40%
sensitive and 67% specific for AHI > 30 which classifies severe OSA. This study was included to demonstrate
the point of contention that MS represents and its relationship to OSA. A great deal of variability in regards to
the MSS performance as a predictive tool is seen across many studies likely due to varying demographics,
especially weight, among the participants in each study.31
Discussion:
Sleep medicine remains a novel field with the first continuous positive airway pressure mask not
utilized until 1981-1982. Furthermore, clinical studies that were “well designed with a large patient base” did
not exist until 2000.2 As a result research remains limited in regards to MS and its association with OSA.
Studies showing that MS is not a reliable predictor suggest that MS is not a tool to be regarded independently
when investigating OSA, but should be regarded as a part of a clinical presentation with many factors to be
considered alongside it as is the case with OSA itself.
This study originally began with the hypothesis that MS is a reliable independent predictor of OSA.
However, multiple studies had already been published that evaluated this correlation and came to different
conclusions showing that MS is, or is not, a reliable independent predictor, especially in regards to more mild
forms of OSA.7, 28, 31 This however does not exclude the usefulness of the MSS in regards to the prediction of
OSA. A new hypothesis was then formulated to make this work novel research and goes as follows:
“Mallampati Scoring (MS), when interpreted alongside predictive factors of OSA in a physical examination,
could serve as new criteria to reliably predict the presence of OSA.” In review of the literature investigated in
this paper and the data contained therein, additional investigation is certainly warranted in regards to
correlations between MS, NC, and BMI, in turn, to that of OSA.

8 MALLAMPATI SCORING AND ITS RELATION TO OBSTRUCTIVE SLEEP APNEA, 2017

 As several studies did conclude that BMI does not seem to consistently rise with relative severity or
likelihood of OSA, its implementation as a part of a criteria to predict likelihood of OSA is questionable. It is
possible that much like MS, BMI must be interpreted alongside several other criteria to have meaningful
usefulness to identifying OSA. MS was consistently shown to be strongly correlated to AHI and NC when the
factors were included in the studies.7,12,29
This research does not show that independently MS has use in diagnosing OSA, but could prove useful
if implemented as a part of a battery of criteria that predispose an individual toward OSA. This literature
review is intended to incentivize a study on a large scale that implements MS as a tool in the standard physical
examination. By doing so one would anticipate that the 3-7% of adults believed to be afflicted with the
disease would decrease. 23 More specifically, a hospital that institutes MS, BMI, and NC into its patient’s
medical history would expect that OSA diagnosis among their patient population might rise by comparison to
previous trends. During this process, a connection between increasing BMI, NC, and MS and how these
factors interact with each other as relative severity of OSA rises could serve as a foundation of new criteria
that identify sleep breathing disorders.

9 MALLAMPATI SCORING AND ITS RELATION TO OBSTRUCTIVE SLEEP APNEA, 2017

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