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An alternative technique for nasotracheal intubation.

Abstract: Surgical procedures on structures of the oral cavity or the mandible may require nasotracheal intubation to allow for surgical access. Even with appropriate technique, trauma to the nasopharynx may occur, resulting in bleeding. The authors describe an alternative technique involving the placement of the flanged end of a red rubber catheter over the distal tip of the endotracheal tube (ETT) to decrease the potential for trauma as the ETT passes through the nasopharynx.


Surgical procedures involving the structures of the oral cavity or the mandible may require nasotracheal intubation to allow for unobstructed surgical access. While nasotracheal intubation is frequently performed without difficulty, the potential is greater for trauma (resulting in bleeding) to the structures of the nasopharynx than with orotracheal intubation. This bleeding can sometimes be profuse and potentially require aspiration, obscuring the surgical field or, in the worst scenario, loss of control of the airway. In a prospective series of nasotracheal intubation, the incidence of bleeding can be as high as 70%, even with appropriate technique and experienced personnel. (1-3) We describe a technique in which the endotracheal tube (ETT) is inserted into the proximal end of a red rubber catheter (Figs. 1 and 2) to prevent damage to the nasopharynx during passage. Previous reports of this and other techniques to potentially reduce trauma to the nasopharynx during nasotracheal intubation are reviewed.


Several factors may help increase the likelihood of atraumatic nasotracheal intubation, including appropriate technique without undue force or attempts at further advancement of the ETT if resistance is encountered. Selection of the most patent naris, preparation of the nasopharynx with vasoconstrictors (oxymetazoline, cocaine), progressive dilation with nasal airways, use of a smaller ETT, and lubrication/warming of the ETT all serve to facilitate atraumatic nasotracheal intubation. (4,5) However, even when appropriate technique is used, bleeding may occur and, in specific circumstances, it may become necessary to cancel the surgical procedure.

We present a simple technique using a red rubber catheter applied over the distal end of the ETT, which may facilitate atraumatic nasotracheal intubation. Given the conical shape of the flanged end of the red rubber catheter, this technique provides a gradually increasing object diameter rather than the constant diameter of the distal end of the ETT. This simple and effective technique was originally described by MacKinnon and Harrison (6) in 1979 but is not commonly taught for nasotracheal intubation.

Elwood et al (7) prospectively evaluated the efficacy of this technique in children ranging in age from 4 to 10 years who were undergoing dental surgical procedures. With the use of a red rubber catheter, although the time to successfully perform endotracheal intubation took longer (median, 74 versus 59 s; P = 0.045), there was a decreased incidence of obvious bleeding (9.6 versus 29.4% of patients, P = 0.013) and fewer times that both nares needed to be entered (2 versus 18%, P = 0.008).


Other techniques have been suggested as ways to lessen the potential for trauma and facilitate nasotracheal intubation. Many techniques have included the use of a guide over wire while the ETT is advanced. The guide has included a fiberoptic bronchoscope, nasogastric tube, balloon-tipped catheter, gum elastic bougie, and various types of suction catheters. (8-12) The major focus of the techniques mentioned has been to increase the success rate of nasotracheal intubation with little emphasis on changing the potential for complications. Most importantly, these techniques do not cover the advancing end of the ETT and therefore may not offer the same advantage of the technique we describe. Alternatively, the use of the finger from a sterile glove or a finger cot has been suggested; however, the potential exists for loss of the foreign body into the airway. (13)


Although we describe this technique in the operating room setting, it is applicable to other clinical scenarios when nasotracheal intubation is indicated, including the emergency room or intensive care unit. In addition to being less traumatic, this technique avoids problems with the tube plugging from mucus or tissue and potentially advancing these substances into the trachea. (14,15)

We have learned To fly in the air like birds. And to swim in the sea like fish. But we have not learned The simple act of living together.

-Martin Luther King, Jr.

From the Departments of Child Health and Anesthesiology, University of Missouri, Columbia, MO.

Reprint requests to Joseph D. Tobias, MD, Department of Anesthesiology, 3W40H, University of Missouri, One Hospital Drive, Columbia, MO 65212.Email:

Accepted August 26, 2002.

Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9610-1039


1. Tintinalli JE, Claffey J. Complications of nasotracheal intubation. Ann Emerg Med 1981;10:142-144.

2. Lu PP. Liu HP, Shyr MH, et al. Softened endotracheal tube reduces the incidence and severity of epistaxis following nasotracheal intubation. Acta Anaesthesiol Sin 1998;36:193-197.

3. Kim YC, Lee Sh, Noh GJ, et al. Thermosoftening treatment of the nasotracheal tube before intubation can reduce epistaxis and nasal damage. Anesth Analg 2000;91:698-701.

4. O'Hanlon J, Harper KW. Epistaxis and nasotracheal intubation: Prevention with vasoconstrictor spray. Ir J Med Sci 1994;163:58-60.

5. Lewis JD. Facilitation of nasogastric and nasotracheal intubation with a nasopharyngeal airway. Am J Emerg Med 1986;4:426.

6. MacKinnon AG, Harrison MJ. Nasotracheal intubation. Anaesthesia 1979;34:910-911 (letter).

7. Elwood T, Stillions DM, Woo DW, et al, Nasotracheal intubation: A randomized trail of two methods. Anesthesiology 2002;96:51-53.

8. Sugiura N, Miyake T, Okui K. et al. Increased success of blind nasotracheal intubation through the use of a nasogastric tube as a guide. Anesth Prog 1996;43:58-60.

9. Hughes S, Smith JE. Nasotracheal tube placement over the fiberoptic laryngoscope. Anaesthesia 1996;51:1026-1028.

10. Cossham PM. Nasotracheal tube placement over a bougie. Anaesthesia 1997;52:184-185.

11. Kawamoto M, Shimidzu Y. A balloon catheter for nasal intubation. Anesthesiology 1983;59:484.

12. Meyer RM. Suction catheter to facilitate blind nasal intubation. Anesth Analg 1989;68:701 (letter).

13. Barras JP, Bigler P, Czerniak A. A rare complication of the use of a finger cot to protect the cuff of a tracheal tube during nasotracheal intubation. Intensive Care Med 1993;19:174-175.

14. Williams AR, Burt N, Warren T. Accidental middle turbinectomy: A complication of nasal intubation. Anesthesiology 1999;90:1782-1784.

15. Cohen SP, Anderson PL. Mucoid impaction following nasal intubation in a child with upper respiratory infection. J Clin Anesth 1998;10:327-330.


A 27-year-old, 142-kg (313-lb) man presented to the operating room for bilateral, vertical osteotomies of the mandible. The patient was premedicated intravenously with midazolam and glycopyrrolate and transported to the operating room where routine monitors were applied. Intravenous induction included propofol and fentanyl followed by cisatracurium for a neuromuscular blockade. The nasopharynx was prepared with a 6% cocaine solution, which was applied with cotton tip applicators for 5 minutes. During this time, anesthesia was provided by mask with isoflurane (inspired concentration 2-3%) in 100% oxygen. The cotton applicators were removed and a warmed, lubricated 7.0-mm ETT was passed into the posterior aspect of the nasopharynx. At that point, resistance to further advancement was noted and a gloved finger was inserted into the mouth to determine the cause of the resistance. The finger was passed under the soft palate and a ridge of tissue was felt on the posterior wall of the nasopharynx. Using digital guidance, the ETT was advanced around this ridge of tissue into the oropharynx and into the trachea. A moderate amount of bleeding was noted from the posterior aspect of the nasopharynx. Despite the fact that nasotracheal intubation had been successfully accomplished, the surgeon decided to cancel the procedure because of the potential for airway compromise should bleeding occur from this area postoperatively while the patient's mouth was wired shut. The procedure was canceled, the patient's trachea was extubated without incident, and he was discharged to home with instructions to return in 2 weeks for a second attempt at the procedure.

Two weeks later, the patient returned to the hospital and was prepared in the same way as previously described. After removal of the cotton tip applicators, the flanged end of a 7-French red rubber catheter was positioned over the distal end of a 7.0-mm ETT (Figs. 1 and 2). The narrow (suction tip) end of the red rubber catheter was then passed through the naris into the nasopharynx and grasped with a forceps, which was placed into the mouth, as it was observed in the oropharynx. The red rubber catheter was pulled out through the mouth as the ETT (distal end inside the flanged end of the red rubber catheter) was advanced into the nasopharynx. When the junction of the red rubber catheter and ETT was seen in the oropharynx, the red rubber catheter was removed from the ETT. The ETT was advanced into the trachea under direct vision using standard technique. No bleeding was noted, and the surgical procedure was completed without difficulty.


* Although nasotracheal intubation is frequently performed without difficulty, the structures of the nasopharynx have a greater potential for trauma with bleeding than with orotracheal intubation.

* The conical shape of the flanged end of the red rubber catheter provides a gradually increasing diameter for the advancing edge (rather than the constant diameter of the distal end of the endotracheal tube), thereby minimizing the risk of trauma to the structures of the nasopharynx.

* In addition to the operating room setting, other clinical scenarios (including the emergency room or intensive care unit) should consider this technique for nasotracheal intubation.

Terry L. Ray, Do, and Joseph D. Tobias, MD
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Title Annotation:Case Report
Author:Tobias, Joseph D.
Publication:Southern Medical Journal
Date:Oct 1, 2003
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