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Lastly, an attempt should be made to ascertain any difficulty with the lower airway (glottis, larynx, and trachea). This is particularly important in patients who have experienced a previous airway injury or surgery on their airway, such as a tracheostomy. Observe the patient for hoarseness, stridor, or a previous tracheostomy scar that would suggest a potential underlying tracheal stenosis.

Fig. 6.5 shows visualization of the laryngeal structures at the time of laryngoscopy. Just as the view of the oropharyngeal structures has been classified, the view of the laryngeal structures has been graded from 1 to 4. While there is not a perfect correlation between the oropharyngeal class and the laryngeal grade, we anticipate that a patient with a class 1 oropharyngeal view and no other identified airway abnormalities will have a grade I laryngeal view. Similarly, a class 4 oropharyngeal view predicts difficulty in visualizing laryngeal anatomy.