Impact of Head Position on Laryngeal Exposure During Direct Laryngoscopy: A Randomized Controlled Trial

• Omar Danfour

  Department of Anaesthesia and Intensive Care Unit, Misurata Medical Center, Misurata, Libya. ، Department of Surgery, Faculty of Medicine, Misurata University, Misurata, Libya.

  المؤلف

• Mona Abujazia

  Pharmacology Department, Faculty of Medicine, Misurata University, Misurata, Libya.

  المؤلف

• Fathi Abulifa

  Department of Anaesthesia and Intensive Care Unit, Misurata Medical Center, Misurata, Libya. Department of Surgery, Faculty of Medicine, Misurata University, Misurata, Libya.

  المؤلف

• Ali Amer

  Department of Anaesthesia and Intensive Care, Faculty of Medicine, Sirte University, Libya

  المؤلف

• Misbah Elfagih

  Department of Surgery, Faculty of Medicine, Alrazi University, Misurata, Libya

  المؤلف

Patient head positioning is considered critical for successful tracheal intubation during direct laryngoscopy, yet comparative data on specific positioning techniques remain limited. This study was conducted to prospectively compare laryngeal exposure during direct laryngoscopy across three distinct head positioning techniques in anesthetized patients. Seventy-five ASA I-II patients scheduled for elective surgery were randomly assigned to three groups (n=25 each). Group 1: standard position (head level with body, maximum atlanto-axial extension); Group 2: sniffing position (head elevated 7-8 cm, maximum atlanto-axial extension); Group 3: flexion position (head elevated 7-8 cm, mild atlanto-axial flexion). All patients received standardized anesthesia (propofol 2-2.5 mg/kg, fentanyl 1-2 mcg/kg, rocuronium 0.6 mg/kg). A single experienced anesthesiologist performed all intubations using a Macintosh laryngoscope. Laryngeal views were classified according to Cormack-Lehane grades. Data were analyzed using one-way ANOVA with Student's t-test for pairwise comparisons and chi-square test for categorical variables (p<0.05 considered significant). Group 2 (sniffing position) achieved superior laryngeal visualization: Grade 1 in 64% of patients, Grade 2 in 32%, Grade 3 in 4%, with 96% combined Grade 1-2 success rate. Group 1 (standard position) achieved Grade 1 in 36%, Grade 2 in 44%, Grade 3 in 20%, with 80% combined success. Group 3 (flexion position) achieved Grade 1 in 12%, Grade 2 in 28%, Grade 3 in 40%, Grade 4 in 20%, with only 40% combined success and 20% complete visualization failure. The sniffing position achieves optimal laryngeal visualization and should be the standard default positioning for tracheal intubation. The standard position provides an acceptable alternative for patients with cervical spine pathology. The flexion position should be avoided due to poor visualization outcomes. 

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