Letters to the Editor: Letters & Announcements
To the Editor:
We have several comments regarding the recent paper by Seo et al.1 showing that inserting an esophageal stethoscope into a warmed preformed tracheal tube reduced the incidence and severity of nasal hemorrhage associated with nasothracheal intubation.
First, using simple preinduction clinical tests to estimate the relative patency of the nostrils may not be helpful in determining the more patent nostril.2 Performing a preliminary bilateral fiberoptic nasendoscopy after the induction of anesthesia, to assess intranasal anatomy and select the best nostril, is significantly more sensitive than tests based on air flow.3
Second, we find interesting that when breathing conditions in their patients was equal bilaterally, the selection of the left nostril for intubation was influenced by surgical preference, rather than at random. The mucosa over the lateral turbinates has greater vascularity than the septal mucosa, and the mucosa is not tethered to the underlying bone. The preformed tracheal tubes used in their study had left facing bevels, and during left-sided intubation, the bevel tends to impact directly against the mucosa overlying the lateral turbinate, which can cause bleeding.2 The observed incidence and severity of epistaxis may have been lower had they selected the right nostril when breathing conditions were equal.
Third, after traditional nasotracheal intubation, fiberoptic inspection of the anterior nose has shown that preformed tracheal tubes preferentially traverse the upper nasal pathway, close to the middle turbinate.4 The middle turbinate is easily traumatized, so when resistance is encountered during insertion of a tracheal tube to reduce the risk of epistaxis, we believe that the tube should initially be manipulated in a caudal rather than a cephalad direction.
Jeffrey L. Tong, FRCA
Department of Military Anaesthesia and Critical Care
Royal Centre for Defence Medicine
Livia S. Malanjum, MB ChB
Department of Anaesthesia
University Hospital Birmingham
Birmingham, United Kingdom
1. Seo KS, Kim JH, Yang SM, Kim HJ, Bahk JH, Yum KW. A new technique to reduce epistaxis and enhance navigability during nasotracheal intubation. Anesth Analg 2007;105:1420–24
2. Smith JE, Reid AP. Identifying the more patent nostril before nasotracheal intubation. Anaesthesia 2001;56:258–62
3. Smith JE, Reid AP. Asymptomatic intranasal abnormalities influencing the choice of nostril for nasotracheal intubation. Br J Anaesth 1999;83:882–6
4. Ahmed-Nusrath A, Tong JL, Smith JE. Pathways through the nose for nasal intubation: a comparison of three endotracheal tubes. Br J Anaesth 2008;100:269–74