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The view from the top. Is it worth recording for posterity?

O’Loughlin et al.’s article in the July issue of Anaesthesia [1] raises some issues about the way we consider visualisation and documentation of laryngeal anatomy in relation to tracheal intubation. Articles on airway devices often refer to the laryngeal view that can be obtained as an indicator of intubation difficulty, and for direct laryngoscopy this is a reasonable association to make. The Cormack and Lehane method of scoring laryngeal view [2] is probably the most commonly used in anaesthetic practice, and modifications of the original score from Yentis [3] and Cook [4] have added extra sub-scores in an effort to increase the precision of the information collected. The score may be used in studies to compare the view obtained under different circumstances or using different devices, and it may also be recorded on the anaesthetic chart as an indicator of future laryngeal views. However, it is not ideal as a tool for airway assessment as there may be substantial variation in interpretation of what is seen and what score is recorded [5–8]. As well as inter-rater reliability, there is the question of accuracy of the scoring, that is, the proportion of assessments that were correct. However, in clinical practice, what is correct? The score is based on laryngeal view, but it is not always appreciated that the Cormack and Lehane score is based on the best view that could have been obtained. This, in turn, depends on adequate preparation for laryngoscopy, such as optimal head positioning and experienced assistance. There is also a presumption of a reasonable level of individual skill from the operator, but expertise in laryngoscopy and videolaryngoscopy may be difficult to define [9]. These are variables which may differ between laryngoscopy attempts, and suboptimal conditions will also result in an inaccurate score. A standard of accuracy can, therefore, be defined but may not always be achieved.