Ultrasound measurement of anatomical parameters of the upper airway in adults | Revista Española de Anestesiología y Reanimación (English Edition)

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"apellidos" => "Sala-Blanch" "email" => array:2 [ 0 => "xsala@clinic.ub.es" 1 => "xavi.sala.blanch@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Anatomía, Facultad de Medicina, Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Anestesia Regional, Máster en Competencias Médicas Avanzadas, Facultad de Medicina, Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Hospital Clínic de Barcelona, Departamento de Anatomía, Facultad de Medicina, Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Medición ecográfica de parámetros anatómicos de la vía aérea superior en adultos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 504 "Ancho" => 896 "Tamanyo" => 68401 ] ] "descripcion" => array:1 [ "en" => "Anatomical coronal section of the larynx and trachea, with corresponding ultrasound view." ] ] ] "textoCompleto" => "Background and objectiveLoss of airway control during anaesthetic induction continues to be a cause of cerebral hypoxia and death or permanent ischaemic lesions<a class="elsevierStyleCrossRefs" href="#bib0120">1,2</a> that are proportional to the severity and duration of cerebral ischaemia. Correct airway management depends not only on familiarity with the different airway devices available, but also on an in-depth understanding of airway anatomy, which will allow the anaesthesiologist to make an informed assessment of the airway before proceeding with anaesthesia induction. The criteria traditionally used to predict difficult airway (DA) have low sensitivity, specificity and positive predictive value, above all when used in isolation,<a class="elsevierStyleCrossRefs" href="#bib0120">1,3</a> and new, more reliable objective criteria are needed.Ultrasound is a safe, rapid and reproducible tool that has already proven useful in fields such as regional anaesthesia and evaluation of critical patients.<a class="elsevierStyleCrossRef" href="#bib0135">4</a> The introduction of smaller, point of care ultrasound systems, together with improved image quality, has drastically increased the use of this technology in many specialist fields. However, its application in some promising fields, such as airway management, has yet to be fully explored.Until recently, the study of the airway was limited to a knowledge of the external anatomy. The introduction of ultrasound saw the emergence of descriptive studies of the internal cervical anatomy.<a class="elsevierStyleCrossRef" href="#bib0140">5</a> These studies, however, merely describe the visual characteristics of the ultrasound image without providing more objective data, such as measurements. For this reason, we set out to gather clinical measurements from healthy patients with no standard DA criteria in order to define the ranges of normality, based on the anatomical references provided by the authors of previous studies. In future studies, these parameters can be compared with those of patients presenting difficult glottic visualisation during upper airway management.We present a descriptive anatomical study in which ultrasound was used to define the normal distance ranges between different upper airway structures in adults with no DA criteria.Materials and methodsThis was an observational study in the use of ultrasound to describe the morphological characteristics of the upper airway in adults with no DA criteria (ruled out on the basis of clinical criteria or previous anaesthesia report) with the aim of defining normal parameters. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the inclusion and exclusion criteria. An anatomical dissection stage was included to gather more information, compare measurements, and provide iconographic support.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The study was conducted in a tertiary level university hospital and was approved by the local Clinical Research Ethics Committee. All patients received detailed information about the study and its possible consequences, and all were asked to give both oral and written informed consent before inclusion.The fresh cadaver study was performed in the Human Anatomy and Embryology Laboratory of the Faculty of Medicine of the University of Barcelona. For the purpose of the study, we used an MTurbo ultrasound system (Sonosite, Bothell, USA) with a 6–13MHz multifrequency linear transducer (HL38; Sonosite, Bothell, USA) or a 2–5MHz multifrequency convex transducer (C60xi; Sonosite, Bothell, USA). An anaesthesiologist expert in musculoskeletal ultrasound performed a scan of 3 fresh elderly cadavers (1 woman and 2 men aged over 70 years). The models were placed supine with the head raised on a 3–4cm pillow and with sufficient cervical extension to allow correct positioning of the probe. We obtained axial sections at the level of the second tracheal ring, cricotracheal membrane, cricoid cartilage, cricothyroid membrane, thyroid cartilage, hyoid bone, and floor of the mouth (coronal plane).After obtaining the ultrasound images, we performed layer-by-layer dissection to reveal the upper airway that was extracted in bloc from the suprahyoid to the third tracheal ring. The samples were frozen at −20°C for later sectional study. Twenty-four hours later, one of the samples (male) was sectioned along the mid-sagittal plane to obtain 2 symmetric halves of the upper airway. A second sample was sectioned in the axial plane through the trachea and thyroid cartilage.The in vivo study was performed in adult volunteers, ASA I–II, with no DA criteria. It was either performed or supervised directly by the same anaesthesiologist who performed the cadaver study, using the same ultrasound system. The subjects were placed in the supine position with the head in slight hyperextension. The following measurements were made:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-Internal transverse diameter of the trachea at the level of the second ring.</li><li class="elsevierStyleListItem" id="lsti0010">-Length of the true vocal cord, located by observing its vibration during phonation, and distance from the anterior commissure to the arytenoid cartilage.</li><li class="elsevierStyleListItem" id="lsti0015">-Mean sagittal length of the cricothyroid membrane.</li><li class="elsevierStyleListItem" id="lsti0020">-Mean sagittal length of the cricotracheal membrane.</li><li class="elsevierStyleListItem" id="lsti0025">-Thickness of the floor of the mouth, measured in the coronal plane at the midpoint between the hyoid and the mandible (point of maximum thickness of the mylohyoid muscle). The measurement was made between the skin and the deep plane of the geniyoid muscle.</li><li class="elsevierStyleListItem" id="lsti0030">-Thickness of the musculature of the floor of the mouth, measured in the coronal plane, including the digastric, mylohyoid and genihyoid muscles.</li><li class="elsevierStyleListItem" id="lsti0035">-Mean sagittal distance between the hyoid and mandible, measured from the hyoid bone to the geni process of the mandible.</li><li class="elsevierStyleListItem" id="lsti0040">-Mean sagittal distance between the palate and the floor of the mouth, measured from the beginning of the musculature of the floor of the mouth to the junction of the hard and soft palate.</li><li class="elsevierStyleListItem" id="lsti0045">-Mean distance between the palate and the mandible, measured from the back of the mandible to the junction of the hard and soft palate.</li><li class="elsevierStyleListItem" id="lsti0050">-Degrees of oropharyngeal axis, measurement of the angle formed by the hard and soft palate.</li></ul>The diameter of the trachea, the vocal cord, the cricothyroid membrane, the cricotracheal membrane, and the floor of the mouth in the coronal plane were measured using a linear transducer, while the rest of the parameters were measured with a convex transducer.The data obtained are shown as number of cases and percentages, mean and standard deviation, and medians and quartiles. Demographic variables (sex [M/W], age [grouped by age <50 years and ≥50 years] and body mass index [BMI] [grouped according to BMI <25 and ≥25]) were compared using the non-parametric Mann–Whitney U test. Finally, the correlation between age and height variables and the variables analysed using the Spearman rho test was evaluated.ResultsOf the 51 initial volunteers, 45 were included in the study. Three were excluded due to a history of cervical surgery, 1 due to sleep apnoea syndrome, and 2 due to clinical criteria for DA. Of the remaining 45, 27 were men and 18 women, aged 47±18 years, height 1.68±0.1m, weight 73±12kg and BMI 25±4kg/m2. The quality of the ultrasound scan was considered very good in 20 individuals (44%), good in 22 (49%) and poor in 3 subjects (7%).The diameter of the trachea at the level of the second tracheal ring was 1.3±0.3cm, and the length of the vocal cord was estimated at 1.6±0.5cm (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). The intercartilaginous membranes measured 0.94±0.32cm in the case of the cricothyroid membrane, and 0.3±0.09cm in the case of the cricotracheal membrane (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>). The thickness of the muscles of the floor of the mouth was 1.5±0.26cm, and 2.11±0.34cm when the subcutaneous fatty tissue was included (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia>The distance between the hyoid and the mandible measured 5.35±0.69cm with the neck slightly extended (<a class="elsevierStyleCrossRefs" href="#fig0025">Figs. 5 and 6</a>). Finally, the convex transducer was used to measure the distances from the palate to the floor of the mouth (4.92±0.5cm), from the palate to the anterior border of the mandible (5.51±0.7cm) and the angle formed by the hard palate and soft palate, which was 114°±14° (<a class="elsevierStyleCrossRefs" href="#fig0030">Figs. 6 and 7</a>).<elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia>Gender differences were observed in the length of the vocal cord (27M and 18W) (M: 1.7±0.5 vs. W: 1.3±0.4cm; p=0.002) and the diameter of the trachea (M: 1.4±0.3 vs. W: 1.2±0.2cm; p=0.014). No gender differences were observed in the remaining parameters. The only measurement that was affected by overweight (22 subjects with BMI <25 and 23 subjects with BMI≥25) was the thickness of the floor of the mouth (BMI<25: 1.99±0.28 vs. BMI≥25: 2.23±0.35cm; p=0.015), but not the muscles of the floor of the mouth (BMI<25: 1.48±0.24 vs. BMI≥25: 1.52±0.28; p=0.57). The correlation studies showed no significant difference between age and the different parameters studied. Height was significantly correlated with tracheal diameter (R: 0.501; p<0.001), the length of the vocal cord (R: 0.363; p=0.016), the thickness of the muscles of the floor of mouth (R=0.299; p=0.046), and the distances between the hyoid and the mandible (R: 0,556; p<0.001) and between the mandible and the palate (R: 0.362±0.015).DiscussionIn this study, we used ultrasound to measure the main structures of the upper airway in healthy adults. The measurements were affected by different anthropometric parameters that could be of interest in future studies, since it could, in theory, affect the predictive capacity of difficult glottic access in direct laryngoscopy.Correct airway management relies to a great extent on an in-depth knowledge of the anatomy of the neck. An accurate evaluation of the airway cannot be obtained using clinical parameters, and the theoretical evaluation often differs from the opinion of an airway expert. There is a clear need for objective criteria that will yield more accurate predictions. For this reason, we analysed the correlation between sonoanatomy and the real anatomy of the upper airway in healthy volunteers (with no cervical or airway pathology) and corpse models. We saw that it is relatively simple to identify the different airway structures on the ultrasound image, and that anatomical views obtained by ultrasound correspond to the real anatomy observed in the cadaver models. Our study includes valuable iconographic images that objectively describe the internal anatomy of the neck. These are of great value to anaesthesiologists, and are essential for safe airway management. The image quality was excellent in most cases (93%), and all the measurements of the different anatomical structures could be identified in all patients: tracheal diameter, true vocal cord, cricothyroid membrane, cricotracheal membrane, thickness of the floor of the mouth, thickness of the musculature of the floor of the mouth, palate-floor of the mouth distance, mandible-hyoid distance, soft/hard palate angle, and palate-mandible distance. However, given the characteristics of the sample, the ease with which structures were identified and distances measured in healthy adults cannot necessarily be extrapolated to patients with pathology, the elderly, or patients with DA criteria. Nevertheless, our findings have shown that anthropometric variables (sex and height) affect some of the parameters measured. The impact of these variables should be studied in the future through multivariate statistical analysis, given the relationship between sex and height.The established morphological criteria used in airway evaluation have low sensitivity and specificity in the prediction of DA, particularly when considered in isolation.<a class="elsevierStyleCrossRefs" href="#bib0120">1,3</a> At present, pre-intubation laryngoscopy continues to be the gold standard in airway assessment. Computed tomography and magnetic resonance imaging are particularly useful imaging studies in this context. However, a pre-intubation laryngoscopy report is not always available, and radiological studies are only available for patients with known airway pathology, and will not therefore be available in most cases.Point-of-care ultrasound is a safe, versatile technique that is increasingly used in critical patients.<a class="elsevierStyleCrossRef" href="#bib0135">4</a> Nowadays, state-of-the-art portable devices with good image resolution are available in most surgical suites, intensive care units, emergency rooms, and outpatient departments, and even in the home care setting. Ultrasound is a safe, fast, non-invasive technique that gives clinicians real-time, dynamic images that can aid diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0135">4,6,7</a> In addition, while other imaging techniques require patient positioning and subsequent reconstruction of axial images, ultrasound can be used in different positions and can acquire images in multiple planes. Comparing various imaging studies, authors such as Beale and Rubin claim ultrasound images of the airway obtained using a high frequency transducer are superior to those obtained by MRI or CT.<a class="elsevierStyleCrossRef" href="#bib0135">4</a> Ultrasound has been used for several purposes in the context of airway assessment: to confirm correct tracheal tube placement,<a class="elsevierStyleCrossRefs" href="#bib0155">8,9</a> to estimate the size and location of the tracheal tube in paediatric patients,<a class="elsevierStyleCrossRef" href="#bib0165">10</a> to guide the administration of nerve block for awake intubation,<a class="elsevierStyleCrossRef" href="#bib0170">11</a> to predict full stomach,<a class="elsevierStyleCrossRef" href="#bib0175">12</a> to evaluate cervical masses,<a class="elsevierStyleCrossRef" href="#bib0140">5</a> to locate the cricothyroid membrane in patients with DA,<a class="elsevierStyleCrossRef" href="#bib0180">13</a> to guide percutaneous tracheostomy,<a class="elsevierStyleCrossRef" href="#bib0185">14</a> or in the pre-intubation evaluation of DA parameters,<a class="elsevierStyleCrossRef" href="#bib0190">15</a> to name just a few. However, we were unable to find a description of objective measurements for many of these anatomical structures in the literature.Most of the studies we reviewed merely describe the ultrasound characteristics and relationship between different airway structures, and the few anatomical series that describe normal parameters for the general population provide contradicting data. For example, according to Or et al., the accuracy of 3D ultrasound measurement of the transverse diameter of the subglottic space is overestimated when compared with MRI Images<a class="elsevierStyleCrossRef" href="#bib0145">6</a>; Husein et al. in their study in children claimed it to be underestimated,<a class="elsevierStyleCrossRef" href="#bib0195">16</a> while Gómez-Tamayo and Lakhal et al. consider it accurate.<a class="elsevierStyleCrossRefs" href="#bib0200">17,18</a> These differences arise, in part, because the same structure is measured at a different anatomical level and in a different plane by all theses authors, making it difficult to compare the studies. In addition, the posterior wall of the trachea cannot be visualised due to artefacts created by the intraluminal air column.<a class="elsevierStyleCrossRef" href="#bib0210">19</a> Although these artefacts are used to describe the different elements, they are still merely estimates of what they are believed to represent. It is also interesting to note that many studies have been carried out in different paediatric age groups, chosen because of their superior ultrasound window, which makes comparison impossible.A review of similar studies has shown that our results are comparable. Or et al., for example, in their comparison of ultrasound and MRI measurements, observed that the transverse diameter of the upper trachea measured with ultrasound was 1.50±0.23cm vs. 1.47±0.20cm with MRI,<a class="elsevierStyleCrossRef" href="#bib0145">6</a> while in our study it was 1.4±0.3cm in men and 1.2±0.2cm in women. In our case, the results were gender-weighted, and we observed that differences in the length of the vocal cord and the tracheal diameter correlated significantly with height. As mentioned above, these data suggest that the differences in measurement observed between men and women could be more attributable to the height of the individual than to their gender.We also found weight-related differences. The increased thickness of airway tissue has been traditionally considered a predictor of DA.<a class="elsevierStyleCrossRef" href="#bib0125">2</a> The introduction of ultrasound has allowed clinicians to quantitatively assess the volume of cervical fatty tissue and its correlation with difficult intubation, although studies have so far reported contradictory results,<a class="elsevierStyleCrossRefs" href="#bib0215">20–23</a> and we therefore considered it important to divide our sample according to weight (BMI less and greater than 25). This allowed us to observe differences in the thickness of the floor of the mouth, but not in the thickness of the musculature. Again, height correlated significantly with the thickness of the muscles of the floor of the mouth, in addition to the distances between the hyoid and the mandible, and between the mandible and the palate. Age was not correlated with the rest of the parameters studied.Our study has limitations, insofar as it is not possible to extrapolate the measurements found in a group of patients with very specific characteristics to the general population and, specifically, to the surgical population. It is important to note that, although we studied a large group of volunteers, we only obtained a limited number of anatomical samples, so we were unable to verify the extent to which the ultrasound images matched the samples taken from the cadaver models. Furthermore, although the study population was composed of healthy volunteers who did not meet the usual clinical criteria for DA, laryngoscopy was not performed in any of our subjects. This means that we cannot conclusively exclude the presence of DA in our subjects, and accordingly cannot claim that our sample is wholly representative of patients with normal airway.Another factor to consider is that, as in other studies, ultrasound examination was performed with the subject in the supine position with the neck in slight extension, and not hyperextension, which is the usual position for intubation. Neither did we differentiate between inspiratory and expiratory phase. These differences could modify the ultrasound morphology of the cervical anatomy.Another limitation encountered was the air present between the tongue and palate, which hampered visualisation of these structures. To overcome this obstacle, some authors have filled their subjects’ mouths with water during the ultrasound scan to facilitate transmission.<a class="elsevierStyleCrossRef" href="#bib0140">5</a> However, the contraction of the mouth muscles needed to avoid swallowing the liquid can alter the regional morphology during the study, so we decided to prioritise morphology over image quality.Finally, the study sample consisted of mostly European and South American individuals, to the exclusion of other populations. In addition, data from all participants were pooled for the purpose of analysis, without distinguishing between ethnicities. These data were then compared with other studies, mostly conducted in Eastern countries, that did not distinguish between races either.ConclusionsWe can conclude that ultrasound was a useful tool in the anatomical study of the upper airway, and allowed us to measure the distances between airway structures.Although our sample was limited to adult volunteers with no standard clinical criteria of difficulty airway, it allowed us to define a series of distances considered “normal” and their relationship with anthropometric parameters.Further studies are needed to specifically determine the correlation between the different airway measurements obtained by ultrasound and the different levels of intubation difficulty.Authorship/collaboratorsL. Gómez-López: study design, analysis of the results, preparation of the text and final approval of the manuscript.B. Torres: study design, analysis of the results, preparation of the text and final approval of the manuscript.R. Bergé: study design and final approval of the manuscript.O. Aguirre: follow-up and analysis of the results, and final approval of the manuscript.M. Luis: study design and final approval of the manuscript.L. Gómez-López: study design, follow-up and analysis of the results, preparation of the text and final approval of the manuscript.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1103933" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1044172" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1103932" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1044173" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background and objective" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Authorship/collaborators" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-03-28" "fechaAceptado" => "2018-05-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1044172" "palabras" => array:4 [ 0 => "Upper airway" 1 => "Ultrasound" 2 => "Normal measurements" 3 => "Difficult airway prediction" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1044173" "palabras" => array:4 [ 0 => "Vía aérea superior" 1 => "Ecografía" 2 => "Medidas de normalidad" 3 => "Predicción de vía aérea difícil" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundMost of the works on ultrasound airway anatomy are limited to a morphological description. A study was conducted in order to provide an objective normal range of measurements. Materials and methodsObservational study to describe the ultrasound characteristics of the upper airway in adults without clinical difficult airway criteria, compared to cadaver dissection anatomical models. ResultsThe study included 45 volunteers (27 men and 18 women), and 3 fresh cadavers. The quality of the examination was very good/good in 93% of the cases. Measurements: tracheal diameter (1.3±0.3cm), vocal cord (1.6±0.5cm), cricothyroid membrane (0.94±0.32cm), cricotracheal membrane (0.3±0.09cm), thickness of the muscles in the floor of the mouth (MFM) (1.5±0.26cm), sub-mandibular subcutaneous fat plus MFM (2.11±0.34cm), hyoid-mandible distance (5.35±0.69cm), palate-floor of the mouth distance (4.92±0.5cm), palate-anterior border of the mandible (5.51±0.7cm), and palate-pharynx angle (114±14). Observed differences: Males had a larger tracheal diameter than females (M: 1.4±0.3 vs. F: 1.2±0.2cm, p=0.014). Subject height showed a significant correlation with the tracheal diameter (R: 0.501, p<0.001), as well as the length of the vocal cord (R: 0.363, p=0.016), the thickness of MFM (R=0.299, p=0.046) as well as the hyoid-mandible (R: 0.556; p<0.001) and palate-mandible distances (R: 0.362; p=0.015). ConclusionsUltrasound allows the anatomy of upper airway to be evaluated, as well as to calculate distances between the anatomical structures. The study defines these distances in adult volunteers without clinical difficult airway criteria." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "AntecedentesLa mayoría de los trabajos sobre anatomía ecográfica de la vía aérea (VA) se limitan a la descripción morfológica. Presentamos un estudio cuyo objetivo es ofrecer datos objetivos de medidas de normalidad. Materiales y métodosEstudio observacional para describir con ecografía las características de la VA superior en adultos sin criterios clínicos de VA difícil (VAD) y comparación con modelos anatómicos de disección en cadáver. ResultadosSe incluyó a 45 voluntarios (27 varones y 18 mujeres) y 3 modelos de cadáver. La calidad de la exploración fue muy buena/buena en el 93% de los casos. Mediciones: diámetro traqueal (1,3±0,3cm), cuerda vocal (1,6±0,5cm), membrana tirocricoidea (0,94±0,32cm), membrana cricotraqueal (0,3±0,09cm), grosor de los músculos del suelo de la boca (MSB) (1,5±0,26cm), tejido subcutáneo de la grasa submandibular y MSB (2,11±0,34cm), distancia hioides-mandíbula (5,35±0,69cm), distancia paladar-suelo de la boca (4,92±0,5cm), distancia paladar-borde anterior de la mandíbula (5,51±0,7cm), ángulo de los ejes bucal y faríngeo (114±14). Diferencias observadas: el diámetro traqueal fue mayor en hombres (H: 1,4±0,3 vs. M: 1,2±0,2cm; p=0,014). La altura mostró una correlación significativa con el diámetro traqueal (R: 0,501; p <0,001), la longitud de la cuerda vocal (R: 0,363; p=0,016) y el grosor MSB (R=0,299; p=0,046), así como con las distancias hioides-mandíbula (R: 0,556; p<0,001) y mandíbula-paladar (R: 0,362; p=0,015). ConclusionesLa ecografía permite evaluar la anatomía de la VA superior y calcular distancias entre estructuras anatómicas. En nuestro estudio se definen estas distancias en voluntarios adultos sin criterios clínicos de VAD." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Gómez-López L, Torres B, Bergé R, Aguirre O, Luis M, Sala-Blanch X. Medición ecográfica de parámetros anatómicos de la vía aérea superior en adultos. Rev Esp Anestesiol Reanim. 2018;65:495–503." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program. An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page: <a class="elsevierStyleInterRef" target="_blank" id="intr0005" href="https://www.elsevier.es/redar">https://www.elsevier.es/redar</a>" ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 840 "Ancho" => 1284 "Tamanyo" => 174550 ] ] "descripcion" => array:1 [ "en" => "Anatomical and axial ultrasound slices of the upper airway, at the level of the thyroid (vocal cord) and the third tracheal ring. Cadaver model of the upper airway with axial section at the level of the vocal cord and the trachea." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1735 "Ancho" => 2195 "Tamanyo" => 227304 ] ] "descripcion" => array:1 [ "en" => "Box-plot showing the diameter of the trachea (A) and the length of the vocal cord (B) obtained in the oblique axial plane shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 504 "Ancho" => 896 "Tamanyo" => 68401 ] ] "descripcion" => array:1 [ "en" => "Anatomical coronal section of the larynx and trachea, with corresponding ultrasound view." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1394 "Ancho" => 2086 "Tamanyo" => 202726 ] ] "descripcion" => array:1 [ "en" => "Box-plot of the distances from the cricothyroid (A) and cricotracheal membrane (B)." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1738 "Ancho" => 2189 "Tamanyo" => 223385 ] ] "descripcion" => array:1 [ "en" => "Example of measurements of the musculature of the floor of the mouth obtained in the coronal plane using a linear probe (A and B). Distance A shown as a box plot of the thickness of the omohyoid, mylohyoid and genihyoid muscles. Distance B shows the same distance from the skin at the base of the tongue. Image C was obtained using a convex transducer and shows the box plot of the distance between the geni process of the jaw and the hyoid." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 975 "Ancho" => 1300 "Tamanyo" => 130651 ] ] "descripcion" => array:1 [ "en" => "The anatomical and sagittal ultrasound planes for obtaining the measurements. Cadaver sagittal section of the upper airway showing the different measurements taken: distance from the palate to the base of the tongue (A); the angle observed between the buccal axiss (hard palate) and the pharyngeal axis (soft palate) (B) and the distance from the palate to the geni process of the mandible (C). Distance D corresponds to the measurement of <a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>C." ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1744 "Ancho" => 2184 "Tamanyo" => 212342 ] ] "descripcion" => array:1 [ "en" => "Box-plot of the distances expressed in <a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>." ] ] 7 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="3" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Inclusion criteria<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a></th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Exclusion criteria \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Score<11</td><td class="td" title="table-entry " align="left" valign="top">Known difficult airway \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Value \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Airway or anterior mediastinum pathology (tumours, inflammation, burns, radiodermatitis, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Mouth opening and mandibular subluxation</td><td class="td" title="table-entry " align="left" valign="top">>5cm or luxation>0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cervical spine pathology (trauma, rheumatoid arthritis, spondylitis, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3.5–5cm or luxation=0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Macroglossia (acromegaly, Down syndrome, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><3.5cm or luxation<0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mandibular pathology (temporomandibular ankylosis, micrognathia, retrognathia, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Thyromental distance</td><td class="td" title="table-entry " align="left" valign="top">≥6.5cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tonsil hypertrophy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><6.5cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Airway obstruction (dyspnoea, dysphagia, dysphonia, stridor) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Maximum range of anteroposterior cervical movement</td><td class="td" title="table-entry " align="left" valign="top">>100° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Morbid obesity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">80–100° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Beard \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><80° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Edentation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Mallampati class</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Habitual snoring \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sleep apnoea syndrome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cervical spine surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pregnancy \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1888781.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Source: Adapted from the difficult airway prediction algorithm of the Catalan Society of Anaesthesiology, Critical Care and Pain Management." ] ] ] "descripcion" => array:1 [ "en" => "Inclusion and exclusion criteria." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guías y algoritmos para el manejo de la vía aérea díficil" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. 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Original article

Ultrasound measurement of anatomical parameters of the upper airway in adults

Medición ecográfica de parámetros anatómicos de la vía aérea superior en adultos

L. Gómez-Lópeza, B. Torresb, R. Bergéa, O. Aguirrec, M. Luisa, X. Sala-Blanchd,

Corresponding author

xsala@clinic.ub.es
xavi.sala.blanch@gmail.com

Corresponding author.

a Servicio de Anestesiología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain

b Departamento de Anatomía, Facultad de Medicina, Universitat de Barcelona, Barcelona, Spain

c Anestesia Regional, Máster en Competencias Médicas Avanzadas, Facultad de Medicina, Universitat de Barcelona, Barcelona, Spain

d Hospital Clínic de Barcelona, Departamento de Anatomía, Facultad de Medicina, Universitat de Barcelona, Barcelona, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background and objective</span><p id="par0005" class="elsevierStylePara elsevierViewall">Loss of airway control during anaesthetic induction continues to be a cause of cerebral hypoxia and death or permanent ischaemic lesions<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1&#44;2</span></a> that are proportional to the severity and duration of cerebral ischaemia&#46; Correct airway management depends not only on familiarity with the different airway devices available&#44; but also on an in-depth understanding of airway anatomy&#44; which will allow the anaesthesiologist to make an informed assessment of the airway before proceeding with anaesthesia induction&#46; The criteria traditionally used to predict difficult airway &#40;DA&#41; have low sensitivity&#44; specificity and positive predictive value&#44; above all when used in isolation&#44;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1&#44;3</span></a> and new&#44; more reliable objective criteria are needed&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Ultrasound is a safe&#44; rapid and reproducible tool that has already proven useful in fields such as regional anaesthesia and evaluation of critical patients&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> The introduction of smaller&#44; point of care ultrasound systems&#44; together with improved image quality&#44; has drastically increased the use of this technology in many specialist fields&#46; However&#44; its application in some promising fields&#44; such as airway management&#44; has yet to be fully explored&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Until recently&#44; the study of the airway was limited to a knowledge of the external anatomy&#46; The introduction of ultrasound saw the emergence of descriptive studies of the internal cervical anatomy&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a> These studies&#44; however&#44; merely describe the visual characteristics of the ultrasound image without providing more objective data&#44; such as measurements&#46; For this reason&#44; we set out to gather clinical measurements from healthy patients with no standard DA criteria in order to define the ranges of normality&#44; based on the anatomical references provided by the authors of previous studies&#46; In future studies&#44; these parameters can be compared with those of patients presenting difficult glottic visualisation during upper airway management&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We present a descriptive anatomical study in which ultrasound was used to define the normal distance ranges between different upper airway structures in adults with no DA criteria&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This was an observational study in the use of ultrasound to describe the morphological characteristics of the upper airway in adults with no DA criteria &#40;ruled out on the basis of clinical criteria or previous anaesthesia report&#41; with the aim of defining normal parameters&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the inclusion and exclusion criteria&#46; An anatomical dissection stage was included to gather more information&#44; compare measurements&#44; and provide iconographic support&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The study was conducted in a tertiary level university hospital and was approved by the local Clinical Research Ethics Committee&#46; All patients received detailed information about the study and its possible consequences&#44; and all were asked to give both oral and written informed consent before inclusion&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The fresh cadaver study was performed in the Human Anatomy and Embryology Laboratory of the Faculty of Medicine of the University of Barcelona&#46; For the purpose of the study&#44; we used an MTurbo ultrasound system &#40;Sonosite&#44; Bothell&#44; USA&#41; with a 6&#8211;13<span class="elsevierStyleHsp" style=""></span>MHz multifrequency linear transducer &#40;HL38&#59; Sonosite&#44; Bothell&#44; USA&#41; or a 2&#8211;5<span class="elsevierStyleHsp" style=""></span>MHz multifrequency convex transducer &#40;C60xi&#59; Sonosite&#44; Bothell&#44; USA&#41;&#46; An anaesthesiologist expert in musculoskeletal ultrasound performed a scan of 3 fresh elderly cadavers &#40;1 woman and 2 men aged over 70 years&#41;&#46; The models were placed supine with the head raised on a 3&#8211;4<span class="elsevierStyleHsp" style=""></span>cm pillow and with sufficient cervical extension to allow correct positioning of the probe&#46; We obtained axial sections at the level of the second tracheal ring&#44; cricotracheal membrane&#44; cricoid cartilage&#44; cricothyroid membrane&#44; thyroid cartilage&#44; hyoid bone&#44; and floor of the mouth &#40;coronal plane&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">After obtaining the ultrasound images&#44; we performed layer-by-layer dissection to reveal the upper airway that was extracted in bloc from the suprahyoid to the third tracheal ring&#46; The samples were frozen at &#8722;20<span class="elsevierStyleHsp" style=""></span>&#176;C for later sectional study&#46; Twenty-four hours later&#44; one of the samples &#40;male&#41; was sectioned along the mid-sagittal plane to obtain 2 symmetric halves of the upper airway&#46; A second sample was sectioned in the axial plane through the trachea and thyroid cartilage&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The in vivo study was performed in adult volunteers&#44; ASA I&#8211;II&#44; with no DA criteria&#46; It was either performed or supervised directly by the same anaesthesiologist who performed the cadaver study&#44; using the same ultrasound system&#46; The subjects were placed in the supine position with the head in slight hyperextension&#46; The following measurements were made&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Internal transverse diameter of the trachea at the level of the second ring&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Length of the true vocal cord&#44; located by observing its vibration during phonation&#44; and distance from the anterior commissure to the arytenoid cartilage&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Mean sagittal length of the cricothyroid membrane&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Mean sagittal length of the cricotracheal membrane&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Thickness of the floor of the mouth&#44; measured in the coronal plane at the midpoint between the hyoid and the mandible &#40;point of maximum thickness of the mylohyoid muscle&#41;&#46; The measurement was made between the skin and the deep plane of the geniyoid muscle&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">Thickness of the musculature of the floor of the mouth&#44; measured in the coronal plane&#44; including the digastric&#44; mylohyoid and genihyoid muscles&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall">Mean sagittal distance between the hyoid and mandible&#44; measured from the hyoid bone to the geni process of the mandible&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">Mean sagittal distance between the palate and the floor of the mouth&#44; measured from the beginning of the musculature of the floor of the mouth to the junction of the hard and soft palate&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0090" class="elsevierStylePara elsevierViewall">Mean distance between the palate and the mandible&#44; measured from the back of the mandible to the junction of the hard and soft palate&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Degrees of oropharyngeal axis&#44; measurement of the angle formed by the hard and soft palate&#46;</p></li></ul></p><p id="par0100" class="elsevierStylePara elsevierViewall">The diameter of the trachea&#44; the vocal cord&#44; the cricothyroid membrane&#44; the cricotracheal membrane&#44; and the floor of the mouth in the coronal plane were measured using a linear transducer&#44; while the rest of the parameters were measured with a convex transducer&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The data obtained are shown as number of cases and percentages&#44; mean and standard deviation&#44; and medians and quartiles&#46; Demographic variables &#40;sex &#91;M&#47;W&#93;&#44; age &#91;grouped by age &#60;50 years and &#8805;50 years&#93; and body mass index &#91;BMI&#93; &#91;grouped according to BMI &#60;25 and &#8805;25&#93;&#41; were compared using the non-parametric Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test&#46; Finally&#44; the correlation between age and height variables and the variables analysed using the Spearman rho test was evaluated&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0110" class="elsevierStylePara elsevierViewall">Of the 51 initial volunteers&#44; 45 were included in the study&#46; Three were excluded due to a history of cervical surgery&#44; 1 due to sleep apnoea syndrome&#44; and 2 due to clinical criteria for DA&#46; Of the remaining 45&#44; 27 were men and 18 women&#44; aged 47<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18 years&#44; height 1&#46;68<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;1<span class="elsevierStyleHsp" style=""></span>m&#44; weight 73<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>kg and BMI 25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#46; The quality of the ultrasound scan was considered very good in 20 individuals &#40;44&#37;&#41;&#44; good in 22 &#40;49&#37;&#41; and poor in 3 subjects &#40;7&#37;&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The diameter of the trachea at the level of the second tracheal ring was 1&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3<span class="elsevierStyleHsp" style=""></span>cm&#44; and the length of the vocal cord was estimated at 1&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>cm &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; The intercartilaginous membranes measured 0&#46;94<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;32<span class="elsevierStyleHsp" style=""></span>cm in the case of the cricothyroid membrane&#44; and 0&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;09<span class="elsevierStyleHsp" style=""></span>cm in the case of the cricotracheal membrane &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46; The thickness of the muscles of the floor of the mouth was 1&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;26<span class="elsevierStyleHsp" style=""></span>cm&#44; and 2&#46;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;34<span class="elsevierStyleHsp" style=""></span>cm when the subcutaneous fatty tissue was included &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">The distance between the hyoid and the mandible measured 5&#46;35<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;69<span class="elsevierStyleHsp" style=""></span>cm with the neck slightly extended &#40;<a class="elsevierStyleCrossRefs" href="#fig0025">Figs&#46; 5 and 6</a>&#41;&#46; Finally&#44; the convex transducer was used to measure the distances from the palate to the floor of the mouth &#40;4&#46;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; from the palate to the anterior border of the mandible &#40;5&#46;51<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;7<span class="elsevierStyleHsp" style=""></span>cm&#41; and the angle formed by the hard palate and soft palate&#44; which was 114&#176;<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#176; &#40;<a class="elsevierStyleCrossRefs" href="#fig0030">Figs&#46; 6 and 7</a>&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Gender differences were observed in the length of the vocal cord &#40;27<span class="elsevierStyleHsp" style=""></span>M and 18<span class="elsevierStyleHsp" style=""></span>W&#41; &#40;M&#58; 1&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5 vs&#46; W&#58; 1&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;4<span class="elsevierStyleHsp" style=""></span>cm&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41; and the diameter of the trachea &#40;M&#58; 1&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3 vs&#46; W&#58; 1&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;2<span class="elsevierStyleHsp" style=""></span>cm&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;014&#41;&#46; No gender differences were observed in the remaining parameters&#46; The only measurement that was affected by overweight &#40;22 subjects with BMI <span class="elsevierStyleMonospace">&#60;</span>25 and 23 subjects with BMI<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>25&#41; was the thickness of the floor of the mouth &#40;BMI<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>25&#58; 1&#46;99<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;28 vs&#46; BMI<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>25&#58; 2&#46;23<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;35<span class="elsevierStyleHsp" style=""></span>cm&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;015&#41;&#44; but not the muscles of the floor of the mouth &#40;BMI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>25&#58; 1&#46;48<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;24 vs&#46; BMI<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>25&#58; 1&#46;52<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;28&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;57&#41;&#46; The correlation studies showed no significant difference between age and the different parameters studied&#46; Height was significantly correlated with tracheal diameter &#40;<span class="elsevierStyleItalic">R</span>&#58; 0&#46;501&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; the length of the vocal cord &#40;<span class="elsevierStyleItalic">R</span>&#58; 0&#46;363&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;016&#41;&#44; the thickness of the muscles of the floor of mouth &#40;<span class="elsevierStyleItalic">R</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;299&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;046&#41;&#44; and the distances between the hyoid and the mandible &#40;<span class="elsevierStyleItalic">R</span>&#58; 0&#44;556&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001<span class="elsevierStyleMonospace">&#41;</span> and between the mandible and the palate &#40;<span class="elsevierStyleItalic">R</span>&#58; 0&#46;362<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;015&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">In this study&#44; we used ultrasound to measure the main structures of the upper airway in healthy adults&#46; The measurements were affected by different anthropometric parameters that could be of interest in future studies&#44; since it could&#44; in theory&#44; affect the predictive capacity of difficult glottic access in direct laryngoscopy&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Correct airway management relies to a great extent on an in-depth knowledge of the anatomy of the neck&#46; An accurate evaluation of the airway cannot be obtained using clinical parameters&#44; and the theoretical evaluation often differs from the opinion of an airway expert&#46; There is a clear need for objective criteria that will yield more accurate predictions&#46; For this reason&#44; we analysed the correlation between sonoanatomy and the real anatomy of the upper airway in healthy volunteers &#40;with no cervical or airway pathology&#41; and corpse models&#46; We saw that it is relatively simple to identify the different airway structures on the ultrasound image&#44; and that anatomical views obtained by ultrasound correspond to the real anatomy observed in the cadaver models&#46; Our study includes valuable iconographic images that objectively describe the internal anatomy of the neck&#46; These are of great value to anaesthesiologists&#44; and are essential for safe airway management&#46; The image quality was excellent in most cases &#40;93&#37;&#41;&#44; and all the measurements of the different anatomical structures could be identified in all patients&#58; tracheal diameter&#44; true vocal cord&#44; cricothyroid membrane&#44; cricotracheal membrane&#44; thickness of the floor of the mouth&#44; thickness of the musculature of the floor of the mouth&#44; palate-floor of the mouth distance&#44; mandible-hyoid distance&#44; soft&#47;hard palate angle&#44; and palate-mandible distance&#46; However&#44; given the characteristics of the sample&#44; the ease with which structures were identified and distances measured in healthy adults cannot necessarily be extrapolated to patients with pathology&#44; the elderly&#44; or patients with DA criteria&#46; Nevertheless&#44; our findings have shown that anthropometric variables &#40;sex and height&#41; affect some of the parameters measured&#46; The impact of these variables should be studied in the future through multivariate statistical analysis&#44; given the relationship between sex and height&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The established morphological criteria used in airway evaluation have low sensitivity and specificity in the prediction of DA&#44; particularly when considered in isolation&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1&#44;3</span></a> At present&#44; pre-intubation laryngoscopy continues to be the gold standard in airway assessment&#46; Computed tomography and magnetic resonance imaging are particularly useful imaging studies in this context&#46; However&#44; a pre-intubation laryngoscopy report is not always available&#44; and radiological studies are only available for patients with known airway pathology&#44; and will not therefore be available in most cases&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Point-of-care ultrasound is a safe&#44; versatile technique that is increasingly used in critical patients&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> Nowadays&#44; state-of-the-art portable devices with good image resolution are available in most surgical suites&#44; intensive care units&#44; emergency rooms&#44; and outpatient departments&#44; and even in the home care setting&#46; Ultrasound is a safe&#44; fast&#44; non-invasive technique that gives clinicians real-time&#44; dynamic images that can aid diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4&#44;6&#44;7</span></a> In addition&#44; while other imaging techniques require patient positioning and subsequent reconstruction of axial images&#44; ultrasound can be used in different positions and can acquire images in multiple planes&#46; Comparing various imaging studies&#44; authors such as Beale and Rubin claim ultrasound images of the airway obtained using a high frequency transducer are superior to those obtained by MRI or CT&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> Ultrasound has been used for several purposes in the context of airway assessment&#58; to confirm correct tracheal tube placement&#44;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">8&#44;9</span></a> to estimate the size and location of the tracheal tube in paediatric patients&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> to guide the administration of nerve block for awake intubation&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> to predict full stomach&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> to evaluate cervical masses&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a> to locate the cricothyroid membrane in patients with DA&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a> to guide percutaneous tracheostomy&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a> or in the pre-intubation evaluation of DA parameters&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a> to name just a few&#46; However&#44; we were unable to find a description of objective measurements for many of these anatomical structures in the literature&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Most of the studies we reviewed merely describe the ultrasound characteristics and relationship between different airway structures&#44; and the few anatomical series that describe normal parameters for the general population provide contradicting data&#46; For example&#44; according to Or et al&#46;&#44; the accuracy of 3D ultrasound measurement of the transverse diameter of the subglottic space is overestimated when compared with MRI Images<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a>&#59; Husein et al&#46; in their study in children claimed it to be underestimated&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a> while G&#243;mez-Tamayo and Lakhal et al&#46; consider it accurate&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">17&#44;18</span></a> These differences arise&#44; in part&#44; because the same structure is measured at a different anatomical level and in a different plane by all theses authors&#44; making it difficult to compare the studies&#46; In addition&#44; the posterior wall of the trachea cannot be visualised due to artefacts created by the intraluminal air column&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a> Although these artefacts are used to describe the different elements&#44; they are still merely estimates of what they are believed to represent&#46; It is also interesting to note that many studies have been carried out in different paediatric age groups&#44; chosen because of their superior ultrasound window&#44; which makes comparison impossible&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">A review of similar studies has shown that our results are comparable&#46; Or et al&#46;&#44; for example&#44; in their comparison of ultrasound and MRI measurements&#44; observed that the transverse diameter of the upper trachea measured with ultrasound was 1&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;23<span class="elsevierStyleHsp" style=""></span>cm vs&#46; 1&#46;47<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;20<span class="elsevierStyleHsp" style=""></span>cm with MRI&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a> while in our study it was 1&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3<span class="elsevierStyleHsp" style=""></span>cm in men and 1&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;2<span class="elsevierStyleHsp" style=""></span>cm in women&#46; In our case&#44; the results were gender-weighted&#44; and we observed that differences in the length of the vocal cord and the tracheal diameter correlated significantly with height&#46; As mentioned above&#44; these data suggest that the differences in measurement observed between men and women could be more attributable to the height of the individual than to their gender&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">We also found weight-related differences&#46; The increased thickness of airway tissue has been traditionally considered a predictor of DA&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> The introduction of ultrasound has allowed clinicians to quantitatively assess the volume of cervical fatty tissue and its correlation with difficult intubation&#44; although studies have so far reported contradictory results&#44;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">20&#8211;23</span></a> and we therefore considered it important to divide our sample according to weight &#40;BMI less and greater than 25&#41;&#46; This allowed us to observe differences in the thickness of the floor of the mouth&#44; but not in the thickness of the musculature&#46; Again&#44; height correlated significantly with the thickness of the muscles of the floor of the mouth&#44; in addition to the distances between the hyoid and the mandible&#44; and between the mandible and the palate&#46; Age was not correlated with the rest of the parameters studied&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Our study has limitations&#44; insofar as it is not possible to extrapolate the measurements found in a group of patients with very specific characteristics to the general population and&#44; specifically&#44; to the surgical population&#46; It is important to note that&#44; although we studied a large group of volunteers&#44; we only obtained a limited number of anatomical samples&#44; so we were unable to verify the extent to which the ultrasound images matched the samples taken from the cadaver models&#46; Furthermore&#44; although the study population was composed of healthy volunteers who did not meet the usual clinical criteria for DA&#44; laryngoscopy was not performed in any of our subjects&#46; This means that we cannot conclusively exclude the presence of DA in our subjects&#44; and accordingly cannot claim that our sample is wholly representative of patients with normal airway&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Another factor to consider is that&#44; as in other studies&#44; ultrasound examination was performed with the subject in the supine position with the neck in slight extension&#44; and not hyperextension&#44; which is the usual position for intubation&#46; Neither did we differentiate between inspiratory and expiratory phase&#46; These differences could modify the ultrasound morphology of the cervical anatomy&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Another limitation encountered was the air present between the tongue and palate&#44; which hampered visualisation of these structures&#46; To overcome this obstacle&#44; some authors have filled their subjects&#8217; mouths with water during the ultrasound scan to facilitate transmission&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a> However&#44; the contraction of the mouth muscles needed to avoid swallowing the liquid can alter the regional morphology during the study&#44; so we decided to prioritise morphology over image quality&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Finally&#44; the study sample consisted of mostly European and South American individuals&#44; to the exclusion of other populations&#46; In addition&#44; data from all participants were pooled for the purpose of analysis&#44; without distinguishing between ethnicities&#46; These data were then compared with other studies&#44; mostly conducted in Eastern countries&#44; that did not distinguish between races either&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0185" class="elsevierStylePara elsevierViewall">We can conclude that ultrasound was a useful tool in the anatomical study of the upper airway&#44; and allowed us to measure the distances between airway structures&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Although our sample was limited to adult volunteers with no standard clinical criteria of difficulty airway&#44; it allowed us to define a series of distances considered &#8220;normal&#8221; and their relationship with anthropometric parameters&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Further studies are needed to specifically determine the correlation between the different airway measurements obtained by ultrasound and the different levels of intubation difficulty&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Authorship&#47;collaborators</span><p id="par0200" class="elsevierStylePara elsevierViewall">L&#46; G&#243;mez-L&#243;pez&#58; study design&#44; analysis of the results&#44; preparation of the text and final approval of the manuscript&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">B&#46; Torres&#58; study design&#44; analysis of the results&#44; preparation of the text and final approval of the manuscript&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">R&#46; Berg&#233;&#58; study design and final approval of the manuscript&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">O&#46; Aguirre&#58; follow-up and analysis of the results&#44; and final approval of the manuscript&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">M&#46; Luis&#58; study design and final approval of the manuscript&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">L&#46; G&#243;mez-L&#243;pez&#58; study design&#44; follow-up and analysis of the results&#44; preparation of the text and final approval of the manuscript&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Most of the works on ultrasound airway anatomy are limited to a morphological description&#46; A study was conducted in order to provide an objective normal range of measurements&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Observational study to describe the ultrasound characteristics of the upper airway in adults without clinical difficult airway criteria&#44; compared to cadaver dissection anatomical models&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The study included 45 volunteers &#40;27 men and 18 women&#41;&#44; and 3 fresh cadavers&#46; The quality of the examination was very good&#47;good in 93&#37; of the cases&#46; Measurements&#58; tracheal diameter &#40;1&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; vocal cord &#40;1&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; cricothyroid membrane &#40;0&#46;94<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;32<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; cricotracheal membrane &#40;0&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;09<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; thickness of the muscles in the floor of the mouth &#40;MFM&#41; &#40;1&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;26<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; sub-mandibular subcutaneous fat plus MFM &#40;2&#46;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;34<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; hyoid-mandible distance &#40;5&#46;35<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;69<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; palate-floor of the mouth distance &#40;4&#46;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; palate-anterior border of the mandible &#40;5&#46;51<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;7<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; and palate-pharynx angle &#40;114<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#41;&#46; Observed differences&#58; Males had a larger tracheal diameter than females &#40;M&#58; 1&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3 vs&#46; F&#58; 1&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;2<span class="elsevierStyleHsp" style=""></span>cm&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;014&#41;&#46; Subject height showed a significant correlation with the tracheal diameter &#40;<span class="elsevierStyleItalic">R</span>&#58; 0&#46;501&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; as well as the length of the vocal cord &#40;<span class="elsevierStyleItalic">R</span>&#58; 0&#46;363&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;016&#41;&#44; the thickness of MFM &#40;<span class="elsevierStyleItalic">R</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;299&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;046&#41; as well as the hyoid-mandible &#40;<span class="elsevierStyleItalic">R</span>&#58; 0&#46;556&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and palate-mandible distances &#40;<span class="elsevierStyleItalic">R</span>&#58; 0&#46;362&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;015&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ultrasound allows the anatomy of upper airway to be evaluated&#44; as well as to calculate distances between the anatomical structures&#46; The study defines these distances in adult volunteers without clinical difficult airway criteria&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La mayor&#237;a de los trabajos sobre anatom&#237;a ecogr&#225;fica de la v&#237;a a&#233;rea &#40;VA&#41; se limitan a la descripci&#243;n morfol&#243;gica&#46; Presentamos un estudio cuyo objetivo es ofrecer datos objetivos de medidas de normalidad&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional para describir con ecograf&#237;a las caracter&#237;sticas de la VA superior en adultos sin criterios cl&#237;nicos de VA dif&#237;cil &#40;VAD&#41; y comparaci&#243;n con modelos anat&#243;micos de disecci&#243;n en cad&#225;ver&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluy&#243; a 45 voluntarios &#40;27 varones y 18 mujeres&#41; y 3 modelos de cad&#225;ver&#46; La calidad de la exploraci&#243;n fue muy buena&#47;buena en el 93&#37; de los casos&#46; Mediciones&#58; di&#225;metro traqueal &#40;1&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;3<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; cuerda vocal &#40;1&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; membrana tirocricoidea &#40;0&#44;94<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;32<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; membrana cricotraqueal &#40;0&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;09<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; grosor de los m&#250;sculos del suelo de la boca &#40;MSB&#41; &#40;1&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;26<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; tejido subcut&#225;neo de la grasa submandibular y MSB &#40;2&#44;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;34<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; distancia hioides-mand&#237;bula &#40;5&#44;35<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;69<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; distancia paladar-suelo de la boca &#40;4&#44;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; distancia paladar-borde anterior de la mand&#237;bula &#40;5&#44;51<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;7<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; &#225;ngulo de los ejes bucal y far&#237;ngeo &#40;114<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#41;&#46; Diferencias observadas&#58; el di&#225;metro traqueal fue mayor en hombres &#40;H&#58; 1&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;3 vs&#46; M&#58; 1&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;2<span class="elsevierStyleHsp" style=""></span>cm&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;014&#41;&#46; La altura mostr&#243; una correlaci&#243;n significativa con el di&#225;metro traqueal &#40;R&#58; 0&#44;501&#59; p&#160;&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; la longitud de la cuerda vocal &#40;R&#58; 0&#44;363&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;016&#41; y el grosor MSB &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;299&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;046&#41;&#44; as&#237; como con las distancias hioides-mand&#237;bula &#40;R&#58; 0&#44;556&#59; p&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y mand&#237;bula-paladar &#40;R&#58; 0&#44;362&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;015&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La ecograf&#237;a permite evaluar la anatom&#237;a de la VA superior y calcular distancias entre estructuras anat&#243;micas&#46; En nuestro estudio se definen estas distancias en voluntarios adultos sin criterios cl&#237;nicos de VAD&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; G&#243;mez-L&#243;pez L&#44; Torres B&#44; Berg&#233; R&#44; Aguirre O&#44; Luis M&#44; Sala-Blanch X&#46; Medici&#243;n ecogr&#225;fica de par&#225;metros anat&#243;micos de la v&#237;a a&#233;rea superior en adultos&#46; Rev Esp Anestesiol Reanim&#46; 2018&#59;65&#58;495&#8211;503&#46;</p>"
      ]
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        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0011">This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program&#46; An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page&#58; <a class="elsevierStyleInterRef" target="_blank" id="intr0005" href="https://www.elsevier.es/redar">https&#58;&#47;&#47;www&#46;elsevier&#46;es&#47;redar</a></p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Anatomical and axial ultrasound slices of the upper airway&#44; at the level of the thyroid &#40;vocal cord&#41; and the third tracheal ring&#46; Cadaver model of the upper airway with axial section at the level of the vocal cord and the trachea&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Box-plot showing the diameter of the trachea &#40;A&#41; and the length of the vocal cord &#40;B&#41; obtained in the oblique axial plane shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Box-plot of the distances from the cricothyroid &#40;A&#41; and cricotracheal membrane &#40;B&#41;&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Example of measurements of the musculature of the floor of the mouth obtained in the coronal plane using a linear probe &#40;A and B&#41;&#46; Distance A shown as a box plot of the thickness of the omohyoid&#44; mylohyoid and genihyoid muscles&#46; Distance B shows the same distance from the skin at the base of the tongue&#46; Image C was obtained using a convex transducer and shows the box plot of the distance between the geni process of the jaw and the hyoid&#46;</p>"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">The anatomical and sagittal ultrasound planes for obtaining the measurements&#46; Cadaver sagittal section of the upper airway showing the different measurements taken&#58; distance from the palate to the base of the tongue &#40;A&#41;&#59; the angle observed between the buccal axiss &#40;hard palate&#41; and the pharyngeal axis &#40;soft palate&#41; &#40;B&#41; and the distance from the palate to the geni process of the mandible &#40;C&#41;&#46; Distance D corresponds to the measurement of <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>C&#46;</p>"
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Box-plot of the distances expressed in <a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="3" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Inclusion criteria<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Exclusion criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top">Score<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>11</td><td class="td" title="table-entry  " align="left" valign="top">Known difficult airway&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Airway or anterior mediastinum pathology &#40;tumours&#44; inflammation&#44; burns&#44; radiodermatitis&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Mouth opening and mandibular subluxation</td><td class="td" title="table-entry  " align="left" valign="top">&#62;5<span class="elsevierStyleHsp" style=""></span>cm or luxation<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cervical spine pathology &#40;trauma&#44; rheumatoid arthritis&#44; spondylitis&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&#46;5&#8211;5<span class="elsevierStyleHsp" style=""></span>cm or luxation<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Macroglossia &#40;acromegaly&#44; Down syndrome&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#60;3&#46;5<span class="elsevierStyleHsp" style=""></span>cm or luxation<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mandibular pathology &#40;temporomandibular ankylosis&#44; micrognathia&#44; retrognathia&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Thyromental distance</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;6&#46;5<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tonsil hypertrophy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#60;6&#46;5<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Airway obstruction &#40;dyspnoea&#44; dysphagia&#44; dysphonia&#44; stridor&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Maximum range of anteroposterior cervical movement</td><td class="td" title="table-entry  " align="left" valign="top">&#62;100&#176;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Morbid obesity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">80&#8211;100&#176;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Beard&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#60;80&#176;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Edentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Mallampati class</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Habitual snoring&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sleep apnoea syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cervical spine surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pregnancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0005"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005"><span class="elsevierStyleItalic">Source</span>&#58; Adapted from the difficult airway prediction algorithm of the Catalan Society of Anaesthesiology&#44; Critical Care and Pain Management&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Inclusion and exclusion criteria&#46;</p>"
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      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:23 [
            0 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Gu&#237;as y algoritmos para el manejo de la v&#237;a a&#233;rea d&#237;ficil"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46; G&#243;mez-R&#237;os"
                            1 => "L&#46; Gaitini"
                            2 => "I&#46; Matter"
                            3 => "M&#46; Somri"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.redar.2017.07.009"
                      "Revista" => array:6 [
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