Why You Should Know Your Mallampati Score

young man sleeping with mouth open, snoring concept

Do you wonder if you suffer from a sleeping disorder? Or are you unsure if you suffer from obstructive sleep apnea (OSA) which keeps you awake at night? Or do you experience gasping for air during sleep and waking up unrefreshed? The Mallampati score is a non-invasive physical examination that can measure the size and shape of a patient’s tongue and esophageal airway, thus help with a diagnosis. A Mallampati score also predicts how difficult intubating that person will be.

What Is the Mallampati Score?

The Mallampati score, or Mallampati classification in anesthesia, is used to predict the ease of endotracheal intubation. Endotracheal intubation (EI) is a life-saving procedure for people who are unconscious or unable to breathe on their own. EI keeps the airway open and prevents suffocation.

Anesthesia is administered during typical endotracheal intubation. Then, through your mouth, a flexible plastic tube is inserted into your trachea to assist you in breathing.

The windpipe, or the trachea, is a tube that transports oxygen to your lungs. The breathing tube is sized according to your age and throat size. A small cuff of air inflates around the tube after it is inserted to keep it in place.

After being sedated, your anesthesiologist will open your mouth and insert a laryngoscope, a small instrument with a light. This device is used to look inside your larynx or voice box. A flexible plastic tube will be placed in your mouth and passed beyond your vocal cords into the lower portion of your trachea once your vocal cords have been located. A video camera laryngoscope may be used in difficult situations to provide a more detailed view of the airway.

Mallampati Score is named after Indian anesthesiologist Seshagiri Mallampati. The test consists of a visual assessment of the distance between the base of the tongue and the roof of the mouth and thus the amount of working space available. It’s a roundabout way of determining how difficult intubation will be; the Cormack-Lehane classification system, which describes what’s seen using direct laryngoscopy during the intubation process, is more definitive. A high Mallampati score of class 3 or 4 is associated with more difficult intubation and a higher risk of sleep apnea.

Sleep apnea is a potentially fatal sleeping disorder where breathing stops and starts repeatedly. You may have sleep apnea if you snore loudly and are tired even after a whole night’s sleep. The following are the most common types of sleep apnea:

The more common type of sleep apnea occurs when the throat muscles relax. Central sleep apnea occurs when your brain fails to send proper signals to your breathing muscles. People with obstructive and central sleep apnea develop complex sleep apnea syndrome, also known as treatment-emergent central sleep apnea.

Obstructive and central sleep apneas have similar signs and symptoms, making it difficult to tell which type you have. The following are some of the most common signs and symptoms of obstructive and central sleep apnea; if you are snoring loudly, you suffer from episodes in which you stop breathing while sleeping and are reported by someone else once you wake up. Or, during sleep, you are gasping for air or waking with a dry mouth. In addition, a morning migraine, trouble sleeping (insomnia), sleepiness during the day (hypersomnia), difficulty paying attention while awake, and irritability are signs of obstructive and central sleep apnea.

The Mallampati Score system is used daily in myofunctional therapy practice when evaluating patients. It’s a simple way to check out a vital part of the upper airway.

Simply put, it assists the anesthesiologist in determining how much space a patient has in their airway and how much that space may be affecting their health.

closeup of a doctor using a laryngoscope

Who Created The Mallampati Score?

The Mallampati classification is another name for the Mallampati score. It was named after Seshagiri Mallampati, an anesthesiologist.

Seshagiri Rao Mallampati was an anesthesiologist from India. He is best known for proposing the Mallampati score, a non-invasive method for assessing the ease of endotracheal intubation, in 1985. Mallampati was born in 1941 in the Indian state of Andhra Pradesh. He began studying medicine in 1968 at Andhra Medical College, the state’s oldest medical school. Mallampati moved to the United States in 1971 and started his anesthesiology training at the Lahey Clinic in Boston, Massachusetts.

Despite optimal positioning, equipment, and an anatomically normal head and neck, Mallampati encountered a patient whose trachea was difficult to intubate. The uvula and faucial pillars were discovered to be hidden beneath the base of the tongue. Mallampati wrote a letter in 1983 describing difficult intubation in a female patient whose mouth could open wide but whose tongue obscured the faucial pillars and uvula. He theorized that the size of the tongue played a role in predicting complex laryngoscope use because a large tongue would obstruct the oropharynx. Mallampati then made it a point to examine every patient to see if the facial pillars and uvula were visible. The clinical sign of the uvula and faucial pillars being hidden by the base of the tongue helped predict the majority of difficult tracheal intubations.

In 1985, Mallampati and his colleagues published a paper in the Journal of the Canadian Anesthesia Society that included 210 patients. They examined the relationship between decreased soft palate, faucial pillars, uvula visualization, and intubation difficulty.

Mallampati proposed an eponymous classification to determine the ease of intubation after the study revealed an inverse correlation. Mallampati spent the rest of his career at Brigham and Women’s Hospital in Boston. He left his medical practice in 2017.

The Mallampati score was created to help doctors, anesthesiologists, and other healthcare professionals determine how easily a patient could be intubated. Still, it’s now widely used by those who work with the airway. Dr. Samsoon and Dr. Young’s added the 4th class to the Mallampati scoring system.

Some doctors and researchers have looked into the efficacy of using the Mallampati score to assess patients for OSA risk. For example, one of the most common sleep-related breathing disorders is OSA. OSA patients often wake up choking or gasping for air. Even though these episodes usually last less than 30 seconds, the disorder can harm sleep quality and cause excessive daytime sleepiness.

The Mallampati score evaluates the size and shape of a patient’s tongue and esophageal airway on a 1 to 4 scale to predict how difficult intubation will be. The Mallampati score is a good predictor of OSA, especially in children, and can help identify patients who need a sleep study and sleep medicine referral.

doctor examining a child's throat with a tongue depressor, closeup

How Does The Mallampati Score Work?

The score is calculated by asking the patient to open their mouth and protrude their tongue as much as possible while sitting; thus, the patient sits with their head in a neutral position. Their mouth is open during this examination. Next, the assessor looks at the anatomy of the oral cavity, noting whether the base of the uvula, faucial pillars (arches in front of and behind the tonsils), and soft palate are visible. In most cases, scoring is done without phonation. However, the scoring may differ depending on whether the tongue is maximally protruded or the patient is asked to phonate.

Modified Mallampati Scoring

The modified Mallampati classification is a simple scoring system that relates the amount of mouth opening to the size of the tongue. It calculates the amount of space available for direct laryngoscopy oral intubation.

Class I: Soft palate, uvula, fauces, pillar visible, or in other words, the patient’s tonsils, uvula, and soft palate are completely visible

Class II: Soft palate, a significant part of the uvula, fauces visible or, to put it another way, the hard and soft palate, upper tonsils, and uvula are visible.

Class III: Soft palate, the base of uvula visible.

Class IV: Only hard palate visible.

diagram of the Mallampati Score classes

Original Mallampati Scoring

Class 1: Faucial pillars, soft palate, and uvula can be visualized

Class 2: Faucial pillars and soft palate can be visualized, but the base of the tongue masks the uvula.

Class 3: Only soft palate visualized.

Why Does This Score Matter?

The Mallampati score matters because you can quickly get the distance between the base of the tongue and the roof of your mouth measured. The Mallampati Score can also be defined as a method used to help in determining the amount of space and its effect on a patient’s health.

Mallampati scoring appears to be a valuable part of the physical examination of patients before polysomnography, according to the results of the study. In addition, this scoring system may be helpful in clinical settings and prospective sleep-disordered breathing studies because of the independent relationship between the Mallampati score and the presence and severity of obstructive sleep apnea.

An improved Mallampati Score will result from muscle tone and strength changes in the soft palate and throat. As therapy progresses, a patient’s scores can improve to a Class I. Unfortunately, many people, including dentists and doctors, are unaware that a Mallampati Score can be improved.

The Mallampati score is a straightforward test that can accurately predict the presence of obstructive sleep apnea. The Mallampati score (or Mallampati classification) is used in anesthesia to predict intubation ease. The Mallampati score can also determine whether or not a patient has obstructive sleep apnea.

The risk of OSA is more than doubled with each increase of one point on the Mallampati scale. The score from a Mallampati assessment could be helpful during physical examinations because it is non-invasive.

diagram showing normal breathing and obstructive sleep apnea

What Is Obstructive Sleep Apnea?

Sleep apnea is also known as sleep-disordered breathing. It is a condition in which breathing stops or becomes shallow during sleep, followed by choking or gasping episodes that frequently result in waking. OSA is a physical obstruction that prevents airflow by blocking breathing passages. Enlarged tonsils or tongue, a retracted lower jaw, or a relatively thick neck circumference are possible anatomic sources of obstruction. This is distinct from central sleep apnea (CSA) when signals between the brain and muscles that aid breathing are disrupted.

OSA affects 2% to 9% of adults, with most cases going undiagnosed. The apnea-hypopnea index (AHI) assesses OSA severity in many patients, but this method has limitations. “Apnea” is an episode in which breathing stops altogether, whereas “hypopnea” is a partial airway collapse with no complete loss of breath. The AHI divides OSA into three severity categories based on the number of apnea or hypopnea episodes per hour of sleep.

Mild category, with 5 to 15 per hour, Moderate, with 15 to 30 per hour, and severe if more than 30 per hour.

When determining the severity of OSA, doctors will look into other factors. Obesity is a significant predictor of OSA, so the body mass index (BMI) is frequently measured. Obesity is defined as having a BMI of 30 or higher. Doctors also consider other symptoms such as snoring and excessive daytime sleepiness. The gold standard for diagnosing, monitoring, and classifying OSA is polysomnography (sleep study), but its drawbacks include cost and accessibility. As a result, the AHI has long been considered the gold standard for determining the severity of OSA.

It’s worth noting that the AHI assessment has its critics. For example, some studies criticize the Apneas and Hypopneas Index (AHI) for focusing solely on the number of hypopneas and apneas per hour of sleep rather than the duration of each episode, as longer episodes pose a greater risk to the patient’s overall health. Furthermore, patients with the same AHI score may not have the same severity of OSA symptoms due to other factors such as daytime symptoms and age.

When assessing patients for OSA, most doctors will not rely solely on AHI or Mallampati scores. Diagnosing OSA and other forms of sleep apnea is a lengthy process that entails gathering a thorough medical history and a variety of tests and screenings. A physical examination will most likely be performed, including measuring the patient’s neck circumference, checking for enlarged tonsils, and other procedures to determine the nature of the obstruction. In addition, the doctor may order blood tests, pelvic ultrasounds, and other tests to rule out other medical conditions.

The sleep study is another important part of the OSA diagnosis. Patients can be referred to a sleep specialist or clinic for the study, but they can also complete it at home. During the study, AHI is measured along with activity in breathing muscles, blood oxygen levels, and brain and heart activity.

There are various causes of obstructive sleep apnea; even children can be affected by sleep apnea. However, certain factors raise your risk, which include the following:

Weight gain

Obesity increases the risk of sleep apnea significantly. Fat deposits in your upper airway can make it difficult to breathe.

Circumference of the Neck

Airways may be narrower in people with thicker necks.

A Restricted Airway

You may have been born with a narrow throat. Tonsils and adenoids can enlarge and block the airway, especially in children.

Being Male

Men are two to three times more likely than women to suffer from sleep apnea. On the other hand, women are at higher risk if they are overweight, and their risk appears to increase after menopause.

man sleeping with CPAP machine

Getting Older

Sleep apnea affects older people at a much higher rate.

Family Background

Having sleep apnea in your family may increase your risk.

Sedatives, tranquilizers, or alcohol, substances that relax your throat muscles, can exacerbate obstructive sleep apnea.


Obstructive sleep apnea is three times more common in smokers than nonsmokers. In addition, inflammation and fluid retention in the upper airway can be exacerbated by smoking.

Nasal Obstruction

A person is more likely to develop obstructive sleep apnea if they have difficulty breathing through their nose, whether due to anatomical issues or allergies.

Medical Problems

Conditions such as Parkinson’s disease, type 2 diabetes, high blood pressure, and congestive heart failure can increase the risk of obstructive sleep apnea. In addition, polycystic ovary syndrome, hormonal disorders, a history of stroke, and chronic lung diseases like asthma can all raise your risk.

Clinical Significance

Intubation is relatively easy in Mallampati classes I and II but more difficult in Mallampati classes III and IV.

The modified Mallampati score is a good predictor of difficult direct laryngoscopy and intubation but is poor at predicting difficult bag-mask ventilation. While the Mallampati score is helpful in conjunction with other tests to predict airway difficulty, it is insufficiently accurate.

Children with higher Mallampati scores may be at risk for airway compromise. For example, patients with a Mallampati score of 3 or 4 are frequently thought to be at increased risk of OSA because there appears to be a link between sleep-disordered breathing and a higher risk of intubation.

doctor holding an ambu bag

Final Thoughts

The Mallampati score (MS) is one of the anesthetists’ most commonly used clinical tests during preoperative physical examination. For example, during tracheal intubation, the goal is to see if the upper airways can be seen easily. The Mallampati score helps infer if the upper airways can be visualized. Thus, the higher the score, the more likely intubation will be difficult. Your anesthetist knowing your Mallampati score could be the difference between a safe and easy intubation and a difficult, scary one.

Was this article helpful?