Ultrasonography – a new method for airway assessment: a review of the literature
DOI:
https://doi.org/10.2478/AMB-2025-0066Keywords:
endotracheal intubation, difficult airway, ultrasonographyAbstract
Introduction: Endotracheal intubation is an important part of the anesthetic practice; however, sometimes, it can be difficult and/or impossible. Complications of difficult airway management include hypoxia, hypoxic brain injury, cardiovascular instability, cardiac arrhythmias and death. The objective of the current review is to determine the feasibility and advantages of ultrasonography as a method for airway assessment in patients undergoing laryngeal surgery. Materials and Methods: The literature review is conducted using the PubMed, Scopus and Google Scholar scientific databases to identify relevant studies and clinical guidelines related to difficult airway management and methods of assessment. The literature review revealed 16,300 articles during the period from 1 January 2014 to 2024, of which only 54 most closely represented the specific issues. Results and Discussion: There are numerous bedside tests for identifying and evaluating difficult airways, but their sensitivity remains unclear. Ultrasonography is a non-invasive, safe, painless, and easy-to-perform method. It provides dynamic real-time images, as well as detailed anatomical information of the pathological changes of the larynx. Conclusion: According to various studies, ultrasonography has been found to be an effective method for the identification and evaluation of difficult airways in patients undergoing elective surgery.
References
Popov TM, Giragosyan S, Petkova V, et al. Proangiogenic signature in advanced laryngeal carcinoma after microRNA expression profiling. Mol Biol Rep. 2020 Jul 12;47(7):5651–5.
Popov T, Giragosyan S, Petkova V, et al. Regulatory Role of microRNAs in Tumor Angiogenesis. Acta Medica Bulg. 2020 May 1;47(1):67–72.
Marinov T, Popov TM, Belitova M. Laryngeal Mask Ventilation during Tracheostomy Improves Intraoperative Hemodynamic Stability in Patients Undergoing Total Laryngectomy. Acta Medica Bulg. 2019 Oct 1;46(3):5–9.
Belitova M, Ivanov S, Marinov T, et al. Minimally Invasive Radiofrequency Ablation for Large Thyroid Toxic Adenoma. Acta Medica Bulg. 2019 Oct 1;46(3):50–2.
Marinov T, Belitova M, Popov T. Eating desorders in patients after total laryngectomy. Anaesthesiol Intensive Care. 2020;49(2):3–5.
Anushaprasath U, Kumar M, Kamal M, et al. Evaluation and comparison of sonographic difficult airway assessment parameters with clinical airway predictors. J Anaesthesiol Clin Pharmacol . 2023 ;40(3):422-431. doi: 10.4103/joacp.joacp_181_23..
Alp G, Koşucu M. Which test best predicts difficult endotracheal intubation? A prospective cohort study. Ulus Travma Acil Cerrahi Derg. 2023; Apr(29(4):477-485.
Marinov T, Belitova M, Popov T. Algorithm for establishing upper airway patency in patients with laryngeal obstruction. Anaesthesiol Intensive Care. 2019;48(1):7–9.
Popov TM, Marinov T, Rangachev J, et al. Cricotracheal Resection in a Patient with Severe Subglottic Stenosis - Advantages of a Temporary Non-Cannulated Tracheostomy. Balkan Med J. 2017 Mar 15;34(2):165–7.
Wang B, Yao W, Xue Q, et al. Nomograms for predicting difficult airwaybased on ultrasound assessment. 2021 [cited 2024 Jan 12]; Available from: https://doi.org/10.1186/s12871-022-01567-y
Belitova M, Popov T, Marinov T. Delayed respiratory distress after thyroidectomy – another challenge for us: a case report. Gland Surg. 2023 May;12(5):710–5.
Marinov T, Belitova M, Popov T. Somatic problems in patients undergoing laryngectomy. Anaesthesiol Intensive Care. 2015;44(4):30–33.
Gottlieb M, Holladay D, Burns KM, et al. Ultrasound for airway management: An evidence-based review for the emergency clinician. Vol. 38, American Journal of Emergency Medicine. W.B. Saunders; 2020. p. 1007–1013.
Kasinath MpR, Rastogi A, Priya V, et al. Comparison of airway ultrasound indices and clinical assessment for the prediction of difficult laryngoscopy in elective surgical patients: A prospective observational study. Anesth Essays Res. 2021;15(1):51-56.
Wang Z, Jin Y, Zheng Y, et al. Evaluation of preoperative difficult airway prediction methods for adult patients without obvious airway abnormalities: a systematic review and meta-analysis. BMC Anesthesiol. 2024 Jul 17;24(1):242. doi: 10.1186/s12871-024-02627-1.
Zhang J, Teoh WH, Kristensen MS. Ultrasound in Airway Management. Vol. 10, Current Anesthesiology Reports. Springer; 2020. 317–326.
Köse EÖÇ, Tekin M, Cesur S, et al. Evaluation of Neck Ultrasound Measurements as a Difficult Airway Predictor [Internet]. 2023. Available from: https://www.researchsquare.com/article/rs-3088145/v1
Gomes SH, Simões AM, Nunes AM, et al. Useful Ultrasonographic Parameters to Predict Difficult Laryngoscopy and Difficult Tracheal Intubation – A Systematic Review and Meta-Analysis. Vol. 8, Frontiers in Medicine. Frontiers Media S.A.; 2021 May 28;8:671658. doi: 10.3389/fmed.2021.671658.
Petrișor C, Dîrzu D, Trancă S, et al. Preoperative difficult airway prediction using suprahyoid and infrahyoid ultrasonography derived measurements in anesthesiology. Med Ultrason. 2019;21(1):83–88.
Gottlieb M, O'Brien JR, Ferrigno N, Sundaram T. Point-of-care ultrasound for airway management in the emergency and critical care setting. Vol. 11, Clinical and Experimental Emergency Medicine. Korean Society of Emergency Medicine; 2024. 22–32.
Bajracharya GR, Truong AT, Truong DT, Cata JP. Ultrasound-Assisted Evaluation of the airway in clinical anesthesia Practice: past, pre sent and future [Internet]. Insight Medical Publishing. Available from: https://anaesthesia-painmedicine.imedpub.com/articles/ultrasoundassisted-evaluation-ofthe-airway-in-clinical-anesthesiapractice-past-present-and-future.php?aid=7067
Chang MG, Berra L, Bittner EA. Bedside Ultrasound: The Silent Guardian for Upper Airway Assessment and Management. Semin Ultrasound, CT MRI. 2024 Feb;45(1):46–57.
Yadav N, Rudingwa P, Mishra S, Pannerselvam S. Ultrasound measurement of anterior neck soft tissue and tongue thickness to predict difficult laryngoscopy - An observational analytical study. Indian J Anaesth. 2019 Aug 1;63(8):629–634.
Alessandri F, Antenucci G, Piervincenzi E, et al. Ultrasound as a new tool in the assessment of airway difficulties: An observational study. Eur J Anaesthesiol. 2019 Jul 1;36(7):509–515.
Bhagavan S, Nelamangala K. Accuracy of Preoperative Ultrasonographic Airway Assessment in Predicting Difficult Laryngoscopies in Adult Patients. Cureus. 2023 Mar 1;15(3):e35652. doi: 10.7759/cureus.35652.
Zheng J. Role of Anterior Neck Soft Tissue Quantifications by Ultrasound in Predicting Difficult Laryngoscopy. Med Sci Monit. 2014;20:2343–2350.
Fernandez-Vaquero MA, Charco-Mora P, Garcia-Aroca MA, Greif R. Preoperative airway ultrasound assessment in the sniffing position: a prospective observational study. Brazilian J Anesthesiol; 73(5):539–47.
Daggupati H, Maurya I, Singh R, Ravishankar M. Development of a scoring system for predicting difficult intubation using ultrasonography. Indian J Anaesth. 2020 Mar 1;64(3):187–192.
Carsetti A, Sorbello M, Adrario E, et al. Airway Ultrasound as Predictor of Difficult Direct Laryngoscopy: A Systematic Review and Meta-analysis. Vol. 134, Anesthesia and Analgesia. Lippincott Williams and Wilkins; 2022. 740–750.
Hall EA, Showaihi I, Shofer FS, Panebianco NL, Dean AJ. Ultrasound evaluation of the airway in the ED: a feasibility study. Crit Ultrasound J. 2018; 10:3. https://doi.org/10.1186/s13089-018-0083-6
Lin J, Bellinger R, Shedd A, et al. Point-of-Care Ultrasound in Airway Evaluation and Management: A Comprehensive Review. Vol. 13, Diagnostics. Multidisciplinary Digital Publishing Institute (MDPI); 2023 Apr 25;13(9):1541. doi: 10.3390/diagnostics13091541.
Udayakumar GS, Priya L, Narayanan V. Comparison of Ultrasound Parameters and Clinical Parameters in Airway Assessment for Prediction of Difficult Laryngoscopy and Intubation: An Observational Study. Cureus. 2023 Jul 5;15(7):e41392. doi: 10.7759/cureus.41392.
Ni H, Guan C, He G, et al. Ultrasound measurement of laryngeal structures in the parasagittal plane for the prediction of difficult laryngoscopies in Chinese adults. BMC Anesthesiol. 2020 Jun 2;20(1):134. doi: 10.1186/s12871-020-01053-3.
Sethu Siva Kiran D, Devi N, Suntan A, Chalekar Assistant Professor R. Evaluation of efficacy of ultrasonographic airway parameters for predicting difficult airway in patients undergoing elective surgery under general anesthesia-A prospective observational study. Int J Life Sci. 2024;13(9): 244-251.
Dabo-Trubelja A. Point-of-Care Ultrasound: A Review of Ultrasound Parameters for Predicting Difficult Airways. J Vis Exp. 2023 Apr 7;(194):10.3791/64648. doi: 10.3791/64648.
Shetty SR, V.T S. Validation of clinical versus ultrasound parameters in assessment of airway. Trends Anaesth Crit Care. 2020 Dec 1; 35:21–27.
Liaskou C, Vouzounerakis E, Trikoupi A, Staikou C. Evaluation of bedside tests and proposal of a model for predicting difficult laryngoscopy: an observational prospective study. Brazilian J Anesthesiol (English Ed. 2020 Mar;70(2):125–133.
Wang B, Wang M, Yang F, et al. Predicting diffi cult intubation: the hyomental distance ultrasound evaluation is superior to the thyromental distance. Anaesth Crit Care Pain Med. 2022 Dec 1;41(6):101144.
Gomes SH, Canelli R, Corradi F, et al. The Use of Ultrasound in Airway Management: Video in Clinical Anesthesia. Anesth Analg. 2024 Oct 1;139(4):887–890.
Rana S, Verma V, Bhandari S, et al. Point-of-care ultrasound in the airway assessment: A correlation of ultrasonography-guided parameters to the Cormack–Lehane Classification. Saudi J Anaesth. 2018;12(2):292-296. doi: 10.4103/sja.SJA_540_17.
Giordano G, Alessandri F, Zulian A, et al. Preoperative ultrasound prediction of difficult airway management in adult patients. Eur J Anaesthesiol. 2023 May;40(5):313–325.
Petrișor C, Szabo R, Constantinescu C, et al. Ultrasound-based assessment of hyomental distances in neutral, ramped, and maximum hyperextended positions, and derived ratios, for the prediction of difficult airway in the obese population: A pilot diagnostic accuracy study. Anaesthesiol Intensive Ther. 2018 Jun 28;50(2):110–116.
Furia JS, Nadkarni MM. Ultrasound-based assessment of tongue thickness for prediction of difficult laryngoscopy and intubation. 2024 [cited 2024 Oct 29]; Available from: https://journals.lww.com/joacp
Agarwal R, Jain G, Agarwal A, Govil N. Effectiveness of four ultrasonographic parameters as predictors of difficult intubation in patients without anticipated difficult airway. Korean J Anesthesiol. 2021;74(2):134–141.
Yao W, Wang B. Can tongue thickness measured by ultrasonography predict difficult tracheal intubation? Br J Anaesth. 2017;118:601–609.
Wang L, Feng YK, Hong L, et al. Ultrasound for diagnosing new difficult laryngoscopy indicator: a prospective, self-controlled, assessor blinded, observational study. 2019 [cited 2024 Jan 5]; Available from: http://www.chictr.org.cn/showproj.aspx?proj=5465
Zetlaoui PJ. Ultrasonography for airway management. Vol. 40, Anaesthesia Critical Care and Pain Medicine. Elsevier Masson s.r.l.; 2021 Apr;40(2):100821. doi: 10.1016/j.accpm.2021.100821.
Yuan J, Ye H, Tan X, et al. Determinants of difficult laryngoscopy based on upper airway indicators: a prospective observational study. BMC Anesthesiol. 2024 Apr 24;24(1):157. doi: 10.1186/s12871-024-02543-4.
Zheng Z, Ma W, Du R. Effectiveness and validity of midsagittal tongue cross-sectional area and width measured by ultrasound to predict difficult airways. Minerva Anestesiol. 2021 Apr;87(4):403-413. doi: 10.23736/S0375-9393.20.14769-2.
Marinov T, Belitova M, Popov T. Anesthetic problems in patients with laryngeal carcinoma. Anaesthesiol Intensive Care. 2018;47(3):19–21.
Marinov T, Belitova M, Popov T. Ventilatory and haemodynamic pattern in patients undergoing laryngeal fronto-lateral resection. Anaesthesiol Intensive Care. 2018;47(3):6–9.
Stancheva G, Kyurkchiyan S, Petkova V, et al. Higher Expression Levels of miR-1246 in Advanced Laryngeal Carcinoma Are Associated with Elevated Risk of Locoregional Metastasis. Proc Bulg Acad Sci. 2023 Mar 27;76(3):464-472.
Popov TM, Dikov T, Goranova TE, et al. Infiltrazione macrofagica e densità capillare nel carcinoma della laringe. Studio su 52 casi. Acta Otorhinolaryngol Ital. 2015 Oct;35(5):321–324.
Marinov T, Belitova M, Popov T. Laryngeal mask - New chalenges. Anaesthesiol Intensive Care. 2015;44(4):26–29.
Downloads
Published
Issue
Section
License
Copyright (c) 2025 B. Dimitrova, M. Gaydarova, G. Nikolova, T. Ilchev, Z. Jeleva, M. Mladenova (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
You are free to share, copy and redistribute the material in any medium or format under these terms.
Journal Acta Medica Bulgarica 
