LeHeR Maneuver vs Sniffing Position During Video Laryngoscopy in Predicted Difficult Airway

The left head rotation (LeHeR) maneuver, in which the head of the supine patient is rotated 45° to the left, is a simple, equipment-free technique proposed to improve the laryngeal view. Studies using the Percentage of Glottic Opening (POGO) score during video laryngoscopy have reported improvement with LeHeR, but evidence is limited and the maneuver has not been systematically evaluated in patients with a predicted difficult airway. This prospective, observational, self-controlled study aims to compare the POGO score obtained in the sniffing position with that obtained in the 45° LeHeR position in the same adult patients with a modified El-Ganzouri Risk Index (EGRI) score above 4 undergoing elective surgery under general anesthesia with video laryngoscopy. Ease of intubation, number and duration of attempts, need for adjuvant maneuvers, hemodynamic changes, and airway trauma will also be recorded.

Inclusion Criteria: * Age 18-70 years * Scheduled for elective surgery under general anesthesia with video laryngoscopy-guided oral endotracheal intubation * Modified El-Ganzouri Risk Index (EGRI) score above 4 * ASA physical status I-III * Written informed consent Exclusion Criteria: * Limited mouth opening (less than 3 fingerbreadths) * Cervical instability, cervical fixation, active cervical pathology, or previous cervical surgery * High aspiration risk (full stomach, gastroesophageal reflux, hiatal hernia, ileus, pregnancy) * Neck/oropharyngeal mass, facial trauma, or pathology distorting anterior neck anatomy * Emergency surgery * POGO score of 100% in the sniffing position