Do you sweep your tongue with a Miller blade? Understanding the correct technique

October 7, 2025 •

4 min read

In direct laryngoscopy, an essential step involves maneuvering the tongue to achieve a clear view of the vocal cords. A critical question for practitioners is: do you sweep your tongue with a Miller blade? The definitive answer is yes, as it is a crucial maneuver for visualizing the glottis during intubation.

Quick Summary

The Miller blade technique requires a lateral sweep of the tongue to move it out of the line of sight during laryngoscopy. This is necessary because the blade's narrow design otherwise causes the tongue to obscure the laryngeal view.

Key Points

Yes, you must sweep the tongue: Using a Miller blade requires you to deliberately sweep the tongue to the left side of the mouth to gain a clear view of the airway.
Avoids blocked view: Placing the Miller blade in the center of the tongue causes the tongue to obstruct the view due to the blade's narrow profile.
Miller vs. Macintosh technique: The Miller blade directly lifts the epiglottis, while the wider Macintosh blade lifts it indirectly by pressing into the vallecula.
Minimize trauma: To prevent dental or soft tissue injury, always lift the laryngoscope handle upward and away, never using the patient's teeth as a fulcrum.
Pediatric preference: The Miller blade is often the preferred choice for infants and small children because it is more effective at managing a 'floppy' epiglottis.
Precise control needed: Due to its narrower profile, the Miller blade demands more precise tongue control during insertion compared to the Macintosh blade.

The Miller Blade and the Art of Airway Management

Direct laryngoscopy is a fundamental procedure in medicine, providing a direct visual of the larynx to facilitate the placement of an endotracheal tube. A key tool in this process is the laryngoscope, which consists of a handle and an interchangeable blade. While many types of blades exist, two are most commonly used: the curved Macintosh blade and the straight Miller blade. The Miller blade, in particular, is often preferred for infants and small children due to its design, which is better suited for managing a floppy epiglottis, a common feature in younger patients. However, its use extends to adults, especially in cases of specific airway challenges.

Do You Sweep Your Tongue with a Miller Blade? The Definitive Answer

For clinicians, proper technique is paramount to ensure a swift and atraumatic intubation. The question, “do you sweep your tongue with a Miller blade?”, addresses a crucial aspect of this technique. The answer is unequivocally yes. The standard procedure for using both curved and straight laryngoscope blades involves displacing the tongue to the left side of the mouth. The Miller blade is intentionally inserted from the right side of the mouth to achieve this.

Why the Tongue Sweep is Necessary

The sweeping motion is not a detail but a necessity for successful laryngoscopy with a Miller blade. When the blade is advanced, it must move the tongue laterally to prevent it from obstructing the view. The straight blade's narrower profile means that if it is advanced down the center of the tongue, the tongue's bulk will simply pile up around it, completely blocking the practitioner's view of the laryngeal structures, such as the epiglottis and vocal cords. This would render the procedure ineffective and increase the risk of complications from multiple intubation attempts. The sweep ensures the tongue is properly controlled and pinned to the left, allowing for clear visualization.

The Step-by-Step Miller Blade Technique

Mastering the Miller blade requires a methodical approach. The following steps outline the proper procedure, with a focus on controlling the tongue:

Positioning: Place the patient in the 'sniffing position'—head extended and neck slightly flexed—to align the oral, pharyngeal, and tracheal axes.
Insertion: Using your right hand in a "scissor" technique, open the patient's mouth as wide as possible. Insert the Miller blade from the right side of the mouth, deliberately avoiding the teeth.
The Sweep: As you advance the blade, begin to sweep the tongue to the left side of the mouth. The goal is to move the tongue's mass out of your line of sight.
Advance and Lift: Continue to advance the blade until the tip of the epiglottis is visible. The Miller blade is designed to directly lift the epiglottis to expose the glottic opening. Once in position, lift the handle upward and away from the operator, without using the teeth as a fulcrum.
Visualize and Intubate: With the epiglottis lifted, the vocal cords should be visible. Insert the endotracheal tube from the right side of the mouth and guide it through the vocal cords.
Confirmation: Once the tube is in place, confirm proper placement by auscultating breath sounds and using capnography.

Miller vs. Macintosh: A Comparison of Techniques

While both the Miller and Macintosh blades are used for direct laryngoscopy, their techniques differ significantly, particularly in how they manage the epiglottis and tongue. The tongue sweep is a shared initial step, but the final blade placement distinguishes them.


Feature	Miller Blade Technique	Macintosh Blade Technique
Blade Shape	Straight	Curved
Epiglottis Management	The blade tip directly lifts the epiglottis to expose the vocal cords.	The blade tip is placed into the vallecula (the space between the tongue and epiglottis) to indirectly lift the epiglottis.
Tongue Control	A narrower flange makes controlling the tongue more challenging and requires a more precise lateral sweep.	A wider flange offers better control and displacement of the tongue, making the initial tongue sweep somewhat more forgiving.
Clinical Application	Preferred in neonates and infants with a 'floppy' epiglottis and in some difficult adult airways.	The most common blade for adults, used for standard intubations.
Visual Field	Provides a closer, more direct view of the glottis.	Offers a slightly less direct view, as the epiglottis is lifted indirectly.

Risks and Safety Considerations

Improper technique during laryngoscopy can lead to several complications, many of which involve trauma to the oral and laryngeal structures. The risks include:

Dental Trauma: Using the laryngoscope as a lever against the teeth is a common cause of injury and must be avoided. The lifting motion should be upward and away.
Soft Tissue Injury: Poor control of the blade, especially a narrow Miller blade, can lead to cuts or abrasions on the tongue and lips if they are pinched between the blade and teeth.
Loss of View: Failure to effectively sweep and control the tongue will result in an obstructed view, which can lead to multiple, potentially traumatic, attempts at intubation.
Vagal Stimulation: Placing the Miller blade correctly under the epiglottis can stimulate the vagus nerve, which can lead to a decrease in heart rate and blood pressure.

Conclusion: Mastery Through Proper Technique

The question, "do you sweep your tongue with a Miller blade?", points to a core principle of direct laryngoscopy: effective tongue displacement is critical for successful visualization and intubation. The straight Miller blade's design necessitates a deliberate lateral sweep to move the tongue out of the line of sight. Mastering this seemingly simple maneuver, along with the precise upward lifting motion, reduces the risk of complications like dental and soft tissue trauma. By adhering to the proper step-by-step technique, practitioners can ensure patient safety and increase the likelihood of a successful first-pass intubation. Ultimately, the successful management of the tongue is the first vital step toward securing the airway, regardless of the blade used.

NIH article on laryngoscopy as a procedural aid is a useful resource for understanding applications beyond standard intubation.

Frequently Asked Questions

It is important to sweep the tongue to the left because the Miller blade is narrow, and advancing it down the center will cause the tongue to mound up and block your view of the larynx. The sweep moves the tongue out of the way, creating a clear line of sight.

The main difference lies in how the blades interact with the epiglottis. The straight Miller blade's tip is used to lift the epiglottis directly, while the curved Macintosh blade is placed in the vallecula (the space in front of the epiglottis) to lift it indirectly.

No, while the Miller blade is often the preferred tool for infants and young children due to their specific airway anatomy, it is also used in adults, particularly in situations involving difficult airways.

Improper technique can lead to several risks, including dental trauma if the blade is levered against the teeth, and soft tissue damage to the tongue or lips if they are pinched. It also increases the risk of failed intubation attempts.

The paraglossal approach is an alternative technique where a straight blade is inserted in the groove between the tongue and tonsil. It is often used in difficult intubation cases with limited mouth opening or a large tongue to improve glottic visualization.

To prevent dental trauma, the laryngoscope handle must always be lifted upward and away, with the force directed along the axis of the handle. It should never be tilted back against the teeth, which act as a dangerous fulcrum.

Yes, a tongue sweep is standard practice with a curved Macintosh blade as well. The insertion process involves inserting the blade from the right side of the mouth and sweeping the tongue to the left, just as with the Miller blade.