Response to “Cephalometry and risk prediction in airway management: limitations”

We sincerely thank Dr. Ward for his thoughtful and constructive commentary entitled “Cephalometry and risk prediction in airway management: limitations”, submitted in response to our editorial “Diagnostic imaging as a tool for airway risk stratification in anesthesia”. His observations provide an important opportunity to further discuss the evolving role of imaging in modern airway assessment and to clarify the intended scope of our article.

We fully agree that airway management extends far beyond direct laryngoscopy and encompasses several critical domains, including facemask ventilation, supraglottic airway management, oxygenation strategies, and emergency front-of-neck access (1). Contemporary airway management guidelines increasingly prioritize continuous oxygen delivery and overall patient safety throughout airway management, rather than focusing solely on tracheal intubation success (2). In this regard, we agree with Dr. Ward that comprehensive airway assessment must integrate multiple anatomical, physiological, and procedural considerations when defining both primary and rescue airway strategies. We also acknowledge that awake airway management techniques play a central role in patients with anticipated complex airways or combined risk factors. However, the intention of our editorial was not to propose cephalometry as a standalone or comprehensive airway assessment tool, but rather to discuss how imaging-derived anatomical information may serve as an adjunctive component within broader multimodal airway evaluation, particularly in patients already undergoing dentomaxillofacial imaging.

We also agree that airway difficulty is multifactorial and cannot be explained exclusively by craniofacial morphology. Human factors, physiological instability, obesity, emergency scenarios, operator experience, and organizational conditions all substantially influence airway outcomes. Significantly, this broader perspective is increasingly recognized in contemporary airway literature. Our editorial did not intend to reduce airway prediction to skeletal measurements alone, but to highlight that craniofacial morphology remains one relevant component within this multifactorial framework. Indeed, several studies have consistently demonstrated associations between mandibular retrognathia, reduced pharyngeal space, altered hyoid positioning, and increased laryngoscopic difficulty, particularly during direct laryngoscopy.

Dr. Ward also correctly points out that many of the studies cited in our editorial were developed in the context of direct laryngoscopy and that videolaryngoscopy has substantially transformed contemporary airway management. We fully acknowledge this evolution. Current guidelines increasingly support videolaryngoscopy as a first-line approach for difficult airway management because of its ability to improve glottic visualization and facilitate tracheal intubation, with evidence suggesting higher first-pass success rates compared with direct laryngoscopy (2). We also agree that hybrid approaches combining videolaryngoscopy and flexible bronchoscopy may further reduce some limitations traditionally associated with direct laryngoscopy. Even so, we believe that these technological advances do not eliminate the relevance of anatomical assessment. Although videolaryngoscopy often improves glottic exposure, craniofacial morphology may still influence several procedural aspects, including device positioning, insertion trajectory, tube delivery, maneuverability within restricted anatomical spaces, and overall airway strategy selection (2-5). This may be particularly relevant in patients with severe retrognathia, micrognathia, craniofacial asymmetry, restricted mandibular space, tumor-related distortion, or when multiple anatomical and physiological risk factors coexist.

The purpose of the commentary was not intended to suggest that cephalometric findings should predict videolaryngoscopy failure in isolation. Rather, our intention was to emphasize that imaging-derived anatomical information may continue to provide clinically useful complementary information, even in the era of videolaryngoscopy and advanced airway adjuncts. In this context, future studies investigating how cephalometric or radiological parameters may contribute to videolaryngoscope blade selection, adjunct choice, or individualized airway planning would be particularly valuable.

We additionally appreciate the discussion regarding the dynamic nature of the airway. We agree that static imaging modalities such as cephalometry, computed tomography, and magnetic resonance imaging cannot fully reproduce airway behavior during anesthesia, positional changes, or respiratory cycles. This limitation was explicitly acknowledged in our editorial, where we stated that two-dimensional imaging does not capture the full three-dimensional complexity of airway anatomy and should always be interpreted alongside clinical evaluation. We also agree that awake endoscopic techniques provide unique real-time information that static imaging cannot offer. However, these approaches should not necessarily be viewed as competing modalities. Rather, they may be complementary tools used in different clinical scenarios. Imaging remains particularly valuable in preoperative planning, craniofacial assessment, orthognathic patients, tumor-related anatomical distortion, and educational or research settings.

Regarding blind nasotracheal intubation, we appreciate Dr. Ward’s concern and agree that modern airway management increasingly prioritizes visualization-assisted techniques whenever available. Our intention in citing the study by Ito et al. (6) was not to advocate for blind nasotracheal intubation as a preferred contemporary strategy, but instead to illustrate how cephalometric relationships may correlate with airway instrumentation outcomes. We agree that videolaryngoscopy and flexible bronchoscopy represent safer and more reproducible approaches in most current clinical environments.

We also particularly appreciate Dr. Ward’s suggestion regarding future applications of imaging in videolaryngoscope selection and airway adjunct planning. We believe this is an excellent direction for future research. As artificial intelligence, radiomics, and three-dimensional imaging continue to evolve, imaging-based airway assessment may eventually contribute not only to risk prediction, but also to individualized airway strategy selection, device optimization, and procedural planning.

In summary, we believe our perspectives are more complementary than conflicting. Both viewpoints reinforce the same central principle: airway assessment should remain comprehensive, multimodal, and clinically integrated. Imaging should not replace bedside evaluation or dynamic airway assessment, but it may provide additional anatomical insight capable of enriching preoperative decision-making in selected patients and specialized settings.

We thank Dr. Ward once again for his insightful comments and for contributing meaningfully to this important discussion in airway management.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Oral and Maxillofacial Anesthesia. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-2026-0018/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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