Background: Airway management in diabetic patients presents unique challenges due to diabetic stiff joint syndrome affecting atlantooccipital mobility. The modified Mallampati classification traditionally performed in sitting position may have limitations in certain clinical scenarios requiring supine positioning. This study aimed to compare the diagnostic accuracy of modified Mallampati score in sitting versus supine positions for predicting difficult intubation in type 2 diabetic patients.

Methods: A prospective observational study was conducted over one year at a tertiary care center involving 150 adult type 2 diabetic patients scheduled for elective surgery under general anesthesia. Modified Mallampati scores were assessed in both sitting and supine positions preoperatively. Intubation difficulty was evaluated using Cormack-Lehane grading during laryngoscopy. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated for both positions.

Results: The supine position demonstrated superior sensitivity (94.2% vs 45.8%) for predicting difficult intubation compared to sitting position, while sitting position showed better specificity (87.3% vs 68.5%). The area under ROC curve was significantly higher for supine position (0.813 vs 0.665, p<0.001). Difficult intubation was significantly associated with higher BMI (p=0.002) and longer diabetes duration (p=0.015).

Conclusion: Modified Mallampati assessment in supine position provides superior sensitivity for predicting difficult intubation in diabetic patients, making it a valuable alternative when sitting assessment is not feasible, though with reduced specificity compared to traditional sitting evaluation.