Mallampati Score and Sleep Apnea

Written by

Janet Larson, Staff Writer, Sleep Health

Reviewed by

Dr. Michael Breus, PhD, DABSM, FAASM, Clinical Psychologist, Sleep Medicine Expert
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The Mallampati score is a simple, non-invasive tool that health care providers may use to assess a person’s risk of having obstructive sleep apnea (OSA). The Mallampati score alone is not enough to diagnose OSA, but it can help health care providers decide who might benefit from additional testing.

What is the Mallampati Score?

The Mallampati score is a way of measuring the space within a person’s airway. It is a noninvasive test, in which a person sits upright, opens their mouth, and sticks out their tongue. The health care provider then provides a Mallamati score based on whether certain structures in the mouth and throat are visible. 

  • Epiglottis: The epiglottis is a flap of tissue that covers the airway when a person swallows so foods and liquids don’t get into the lungs.
  • Soft palate: The soft palate is the tissue at the back of the roof of the mouth. It moves during talking, swallowing, and to keep food from entering the nasal cavity.
  • Hard palate: The hard palate is a bony area at the front of the roof of the mouth. The hard palate aids in chewing and speaking.
  • Uvula: The uvula is a piece of tissue that hangs from the back of the throat. It helps with swallowing and speech.
  • Tonsillar pillars: The tonsillar pillars are arch-like structures that may be seen on the sides of the back of the throat.

Although originally devised to improve patient safety during procedures involving a breathing tube, researchers found that a person’s Mallampati is also linked to their risk of OSA and its severity. The original Mallampati scoring system has since been modified. The most commonly used Mallampati scoring system is now referred to as the modified Mallampati score.

Mallampati Scoring

The Mallampati score is based on what structures in the mouth and throat are visible to the health care provider when a person’s mouth is open and their tongue is shifted forward.

The following scoring system is used to determine a person’s modified Mallampati score: 

  • Class 1: The soft palate, uvula, and tonsillar pillars can be viewed.
  • Class 2: Just the soft palate and uvula are visible.
  • Class 3: Only the soft palate and the base of the uvula are visible.
  • Class 4: The hard palate is the only structure visible.

Some practitioners also include Class 0, which describes when any part of the epiglottis is visible

People with a score of 3 or 4 are considered to have a narrow airway, which increases their risk of obstructive sleep apnea.

Risk Factors for Obstructive Sleep Apnea

Obstructive sleep apnea is a sleep-related breathing disorder that causes interruptions in breathing during sleep. OSA occurs when the airway collapses repeatedly, restricting the flow of air. A number of individual characteristics can increase a person’s risk of developing obstructive sleep apnea. 

  • Physical features: Certain features of the face or throat make an individual more likely to experience OSA. These include a short lower jaw or a long face. In children, enlarged tonsils and other structures in the throat are major risk factors. 
  • Obesity: Having a high body mass index (BMI) is strongly linked to the risk of developing OSA. Obesity is also a strong risk factor for children.
  • Age: People are more likely to develop OSA as they get older, with the risk leveling off around the age of 70.
  • Male sex: Being assigned male at birth is associated with an increased risk of OSA. People who receive masculinizing gender-affirming hormone therapy are also at an increased risk. 
  • Family history: Some people may have a genetic predisposition to developing obstructive sleep apnea. Researchers believe the tendency for OSA to run in families may also be due to similar physical features, habits, and environments. 

Diagnosing Sleep Apnea with the Mallampati Score

A high Mallampati score cannot diagnose obstructive sleep apnea, but it can help doctors identify if a person is at increased risk due to the structures in their mouth and airway. Along with other factors, a high Mallampati score may persuade a health care provider that further testing with a sleep study is needed. 

When a doctor suspects someone may have obstructive sleep apnea, they will typically evaluate a number of factors. 

  • Risk: Doctors will consider risk factors like sex, obesity, and age when determining who might be at a high risk of OSA. 
  • Symptoms: A health care provider may suspect OSA when someone reports symptoms of sleep apnea such as excessive daytime sleepiness, gasping during sleep, early morning headaches, or snoring. 
  • Coexisting conditions: A number of medical conditions occur more frequently in patients with OSA, including congestive heart failure, high blood pressure, chronic obstructive pulmonary disease, and end-stage kidney disease. 
  • Physical characteristics: Doctors evaluate a number of physical features to determine a person’s risk of OSA, including the size of their neck, waist, and features of their mouth and throat. Assessing the mouth and throat is where the Mallampati score can play a role in diagnosis. 

A sleep study is necessary to confirm a suspected diagnosis of OSA. Based on their assessment of a person’s risk factors and individual needs, a health care provider may order an at-home sleep study or one conducted in a specialized sleep laboratory. 

Frequently Asked Questions about the Mallampati Score

What Is a Normal Mallampati Score?

A score of 2 or lower on the Mallampati scale suggests that the features of a person’s mouth and throat do not increase their risk of obstructive sleep apnea. This score means that at least the soft palate and uvula are visible during an examination.

However, it is important to note that having a low Mallampati score does not mean that a person does not have sleep apnea.

Does Pregnancy Change Your Mallampati Score?

During pregnancy, the size of the airway may narrow and the Mallampati score can increase. In fact, some pregnant people will have their Mallampati scores increase to class 4 in late pregnancy. This may be due to increased fluid and swelling during pregnancy, which narrows the airway. 

Although more research is needed, the rate of obstructive sleep apnea may be higher among pregnant people. Narrowing of the airway is one of the most significant physical changes that may contribute to developing OSA while pregnant. 

Is Mallampati Score Useful for Children

The Mallampati score is particularly useful for children. For every point increase in a child’s Mallampati score, they have a six times higher risk of having obstructive sleep apnea. In contrast, an adult’s risk of OSA only doubles with every point increase in their Mallampati score. 

Using the Mallampati score to predict a child’s risk of OSA can be helpful in deciding when a sleep study should be prescribed.

About The Author

Janet Larson

Staff Writer, Sleep Health

Janet is a freelance writer and editor who lives in Fancy Gap, Virginia. She has a bachelor’s degree in literature from Bennington College and has worked for Fred Hutchinson Cancer Center. Janet particularly likes writing about sleep because it’s both mysterious and ordinary. She says it’s impossible for her to sleep without three pillows.

  • Position: Side sleeper
  • Temperature: Cold Sleeper
  • Chronotype: Dolphin

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