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Long-term betel nut chewing is not a predictor of difficult tracheal intubation.

Unanticipated difficult intubation is still one of the most serious crises in anaesthesia (1). Betel chewing is well recognised as being associated with the pathogenesis of oral submucous fibrosis (OSF) (2). Although OSF with trismus may result in expected difficult intubation, unanticipated difficult intubation has been reported in a patient with OSF even without trismus (3). The authors of this report stated that the absence of trismus in betel chewers may not effectively rule out unanticipated difficult intubation.

With approval from the Ethics Committee of Ditmanson Medical Foundation Chia-Yi Christian Hospital (Ditmanson Medical Foundation Chia-Yi Christian Hospital IRB:097028) we studied the influence of long-term betel nut chewing (daily for over five years) on difficult intubation in 218 males requiring tracheal intubation for elective surgery. Written inform consent was received for all cases. All these patients received tracheal intubation under direct laryngoscopy using a #3 Macintosh blade. After induction, the anaesthestist reported the direct view score according to the Cormack-Lehane grade (4) and an assessment of the difficulty of intubation based on a four-point system: 1=easy, 2=not easy, 3=difficult but possible, 4=extremely difficult, without confidence of successful intubation. In the meantime, a research assistant recorded the time and the number of attempts needed for successful tracheal intubation. Continuous variables were compared using t-test and [chi square] test was used to compare the frequency of categorical variables.

Of the 218 male cases, 105 cases were in the long-term betel nut chewing group (BC) and 113 cases had no betel nut chewing history (Group NBC). Demographic data and preoperative difficult intubation predictors were similar between groups. One patient in the NBC group had a difficult intubation. Cases needing more than one attempt were similar between the two groups (eight cases in each group). The anaesthetists' reports of difficult intubation, the Cormack-Lehane grade and number of attempts needed for successful tracheal intubation were also similar (Table 1). There were 48 cases (22.3%) with a Cormack-Lehane grade [greater than or equal to] 3 (19% in the group BC and 25% in the group NBC) and eight cases (3.7%) with a Cormack-Lehane score=4 (2.8% in the group BC; 4.5% in the group NBC). The reports of intubation grade [greater than or equal to] 3 was 19.7% (a total of 43 cases, with 18.1% in the group BC; 21.2% in the group NBC). Six cases (2.7%) were given a grade of 4 and 3 in each group (2.8% in the group BC; 2.6% in the group NBC). The time to successful intubation was similar also for the two groups (24 [+ or -] 20 vs 27 [+ or -] 16 seconds in Group BC and NBC respectively). There was no significant difference in the number of attempts needed for successful tracheal intubation between groups.

The frequency of OSF is usually low in the general population, but the OSF related to betel nut chewing has been reported as up to 14.3% and even 24.4% in south of Taiwan (5,6). These rates suggest that found about 20 cases in our BC group would have had OSF. However, the CormackLehane grades in both groups were similar, indicating that long-term betel nut chewing is unlikely to be a clinically important predictor for difficult intubation.



H.-P. SU


Taiwan, Republic of China


(1.) Williamson JA, Webb RK, Szekely S, Gillies ER, Dreosti AV The Australian Incident Monitoring Study. Difficult intubation: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21:602-607.

(2.) Lee C-H, Ko Y-C, Huang H-L, Chao Y-Y, Tsai C-C, Shieh T-Y et al. The precancer risk of betel quid chewing, tobacco use and alcohol consumption in oral leukoplakia and oral submucous fibrosis in southern Taiwan. Br J Cancer 2003; 88:366-372.

(3.) Mahajan R, Jain K, Batra YK. Submucous fibrosis secondary to chewing of quids: another cause of unanticipated difficult intubation. Can J Anaesth 2002; 49:309-311.

(4.) Cormack RS, Lehane JR, Adams AP, Carli F. Laryngoscopy grades and percentage glottic opening. Anaesthesia 2000; 55:184.

(5.) Yang YH, Lee HY, Tung S, Shieh TY. Epidemiological survey of oral submucous fibrosis and leukoplakia in aborigines of Taiwan. J Oral Pathol Med 2001; 30:213-219.

(6.) Chung C-H, Yang Y-H, Wang T-Y, Shieh T-Y, Warnakulasuriya S. Oral precancerous disorders associated with areca quid chewing, smoking, and alcohol drinking in southern Taiwan. J Oral Pathol Med 2005; 34:460-466.
Table 1
The difference between betel chewers and non-betel chewers in terms
of Mallampati scores and difficult tracheal intubation-related

 Betel chewer, n=105

Mallampati score: number of I: 48, II: 42, III: 13, IV: 2

Cormack-Lehane grade: number I: 30, II: 54, III: 17, IV: 3
of cases (104:111)

Anaesthetist evaluation of 1: 62, 2: 24, 3: 16, 4: 3
DI: number of cases

Intubation attempts: number 1: 97, 2: 7, 3: 1, >3: 0
of cases

 Non-betel chewer, n=113 P value

Mallampati score: number of I: 44, II: 41, III: 26, IV: 2 0.117

Cormack-Lehane grade: number I: 44, II: 39, III: 23, IV: 5 0.100
of cases (104:111)

Anaesthetist evaluation of 1: 68, 2: 21, 3: 21, 4: 3 0.835
DI: number of cases

Intubation attempts: number 1: 105, 2: 6, 3: 1, >3: 1 0.777
of cases

Cormack Lehane score (1-4; from easiest to most difficult). A
Cormack-Lehane grade was not recorded in one case with and two cases
without betel chewing groups). DI=difficult intubation.
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Title Annotation:Correspondence
Author:Tsai, Y.-S.; Che, P.-C.; Su, H.-P.; Tseng, C.-C.
Publication:Anaesthesia and Intensive Care
Article Type:Letter to the editor
Geographic Code:9CHIN
Date:Mar 1, 2012
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