The 100 essentials in icu and anesthesia

The left molar approach is a technique to improve the view at laryngoscopy using a standard macintosh laryngoscope. It was described by Yamamoto¹ as follows:

• insert the blade from the left corner of the mouth at a point above the left molars;
• the tip of the blade is directed posteromedially along the groove between the tongue and the tonsil until the epiglottis and glottis come into sight;
• before elevating the epiglottis, the tip of the blade is kept in the midline of the vallecula and the blade is kept above the left molars;
• the view provided is framed by the flange, the lingual surface of the blade, and the tongue bulged to right of the blade.

The success of this approach in comparison with alternatives has been reproduced by others². However although Yamamoto and others demonstrated that this improved the laryngoscopic view, actual intubation may still be difficult because of the limited access to the cords, in part caused by the bulging of the tongue.


The take home message ,if I have a grade IV view despite my usual first-pass success optimisation manoeuvres such as positioning, reducing or releasing cricoid pressure, and providing external laryngeal manipulation, it is worth trying the left molar approach  .


1. Left-molar Approach Improves the Laryngeal View in Patients with Difficult LaryngoscopyAnesthesiology. 2000 Jan;92(1):70-4 Full Text
2. Comparative Study Of Molar Approaches Of Laryngoscopy Using Macintosh Versus Flexitip BladeThe Internet Journal of Anesthesiology 2007 : Volume 12 Number 1
3. The use of the left-molar approach for direct laryngoscopy combined with a gum-elastic bougieEuropean Journal of Emergency Medicine December 2010 ;17(6):355-356