• K B Greenland, M J Edwards, N J Hutton, V J Challis, M G Irwin, and J W Sleigh.
• Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital Brisbane, Butterfield Street, Herston, Brisbane, Queensland, Australia. french9a@yahoo.co.uk
• Br J Anaesth. 2010 Nov 1;105(5):683-90.

BackgroundThe sniffing position is often considered optimal for direct laryngoscopy. Another concept of airway configuration involving a laryngeal vestibule axis and two curves has also been suggested. We investigated whether this theory can be supported mathematically and if it supports the sniffing position as being optimal for direct laryngoscopy.MethodsMagnetic resonance imaging scans were performed in 42 normal adult volunteers. The airway passage was divided into two curves-primary (oro-pharyngeal curve) and secondary (pharyngo-glotto-tracheal curve). Airway configuration was evaluated in the neutral, extension, head lift, and sniffing positions. The airway passage, point of inflection (where the two curves meet), its tangent, and the line of sight were plotted on each scan.ResultsThe point of inflection lay within the laryngeal vestibule in all positions. The head lift and sniffing positions caused the tangent to the point of inflection to approximate the horizontal plane. The sniffing, extension, and head lift positions caused a reduction in the area between the line of sight and the airway curve compared with the neutral position.ConclusionsA two-curve theory is proposed as a basis for explaining airway configuration. The changes in these curves with head and neck positioning support the sniffing position as optimal for direct laryngoscopy. Application of this new concept to other forms of laryngoscopy should be investigated.

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