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Nasotracheal tube occlusion from adenoid trauma.

We report a case of inability to ventilate through a nasotracheal tube due to occlusion of the tube by adenoid tissue avulsed during traumatic nasotracheal intubation. This case highlights the importance of preoperative assessment for possible enlarged adenoids in patients at risk and the need to perform a visual check of the nasotracheal tube if difficulty is encountered during its insertion.

A 30-year-old obese woman (BMI 37) presented to us for emergency dental surgery under general anaesthesia for buccal space infection. Besides heavy snoring at night, there was no other symptom suggestive of obstructive sleep apnoea. Airway assessment revealed limited mouth-opening due to pain.

Intravenous induction of anaesthesia with was uneventful. Cophenylcaine spray was applied to both nostrils. A nasotracheal tube (RAE North Size #6.5, Mallinckrodt Medical, Athlone, Ireland) was inserted through the left nostril with mild resistance, after an unsuccessful attempt on the right. During the subsequent direct laryngoscopy, the nasotracheal tube was seen passing through the vocal cords under direct vision. Some blood was also noted in the pharynx.

Following intubation there were high airway pressures and ventilation was unsuccessful with no expired carbon dioxide trace on end-tidal capnography. On withdrawal of the tube, blood-stained tissue resembling adenoid was found to be occluding the tip. The airway was subsequently secured uneventfully via oral intubation.

Fibreoptic nasopharyngoscopy by the otorhinolaryngologist showed that the left adenoid was raw and partially avulsed. In addition, both adenoids were noted to be enlarged and swollen. Blood clots were noted in the posterior nasal space, but there was no active bleeding. The turbinates were intact. The dental procedure proceeded uneventfully and the patient was well postoperatively.

Trauma during nasotracheal intubation is not uncommon. While epistaxis (1) and trauma to the turbinates (2) are frequently reported, reports of trauma to the adenoids are rare. The adenoids may only be at increased risk of trauma if enlarged. The normal adenoids at the roof of the nasopharynx are at considerably less risk compared to the turbinates, nasal septum or nasal mucosa. This may be because the space between the turbinates and nasal septum is the narrowest along the path of the tube (3). In a patient like ours with significant history of snoring, the preoperative consultation should include the assessment for enlarged adenoids. Symptoms and signs of enlarged adenoids such as obstructive sleep apnoea, chronic mouth-breathing and hyponasal speech (4) should be sought. Additional investigations like lateral neck radiographs and fibreoptic nasopharyngoscopy may be useful.

The inability to ventilate after intubation resulted from nasotracheal tube occlusion by avulsed adenoid tissue. Tubal obstruction by foreign bodies (5) and aspiration of turbinates leading to respiratory distress (6) following nasotracheal intubation have been previously reported. Difficult transit of the nasotracheal tube is a risk factor for nasal trauma (3). Hence we recommend that in the event of a difficult transit, visual inspection of the tube for foreign body be performed under direct laryngoscopy to exclude nasotracheal tube occlusion and avoid possible migration of the foreign body into the lower airway during subsequent positive pressure ventilation.


(1.) O'Connell JE, Stevenson DS, Stokes MA. Pathological changes associated with short-term nasal intubation. Anaesthesia 1996; 51:347-350.

(2.) Dost P, Armbruster W Nasal turbinate dislocation caused by nasotracheal intubation. Acta Anesthesiol Scand 1997; 41:795-796.

(3.) Sim WS, Chung IS, Chin JU, Park YS, Cha KJ, Lee SC, Kim YC. Risk factors for epistaxis during nasotracheal intubation. Anaesth Intensive Care 2002; 30:449-452.

(4.) Cummings CW. Otolaryngology Head & Neck Surgery, 4th ed. Philadelphia: Elsevier Mosby, 2005.

(5.) Zar HA, Wu WW. The inability to detect expired carbon dioxide after endotracheal intubation as a result of one-way valve obstruction of the endotracheal tube. Anesth Analg 2001; 93:971-972.

(6.) Cooper R. Bloodless turbinectomy following blind nasal intubation. Anesthesiology 1989; 71:469.



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Author:Ng, S.Y.; Yew, W.S.
Publication:Anaesthesia and Intensive Care
Date:Dec 1, 2006
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