Nasotracheal intubation by means of flexible fibreoptic endoscopy is the method of choice if a difficult intubation is anticipated . Airway management is facilitated in the awake and co-operative patient. In order to reduce or even blunt stressfull reactions, adequate topical analgesia of the nasal mucosa is essential . Bleeding from the nasal mucosa should be prevented, since it impedes the performance of endoscopic intubation. Both objectives can be achieved with the use of cocaine, which is therefore recommended prior to nasal intubation [3-5].
However, cocaine has been shown to inhibit presynaptic noradrenaline and dopamine uptake which leads to their increased availability . The use of cocaine in hypertensive patients, in patients with coronary artery disease or hyperthyroidism could therefore be dangerous. Furthermore, cocaine has a potential for substance abuse. In view of these factors the availability of a viable alternative to cocaine would be desirable.
The present study was designed to investigate whether topical analgesia of the nose for endoscopy with phenylephrine/lignocaine is comparable to topical analgesia with cocaine in terms of vasoconstriction, analgesia and side effects.
Patients and methods
Ninety-nine patients (ASA I, II), requiring nasotracheal intubation for maxillofacial surgery participated in this randomized double-blind study after signing the appropriate informed consent forms and with the approval of the study by the Regional Medical Council Ethics Committee. Patients with history of epistaxis, bleeding disorders, deviation of the nasal septum or adenoids were excluded from the study.
Patients were premedicated with flunitrazepam 1-2 mg orally 1 h before induction and allocated to one of two groups on a random basis to receive into each naris either 0.5 mL 10% cocaine (n=52) or 0.5 mL of 0.25% phenylephrine and 3% lignocaine (1% phenylephrine and 4% lignocaine at a mixing ratio of 1:3) (n=47) respectively.
Following fentanyl 0.1-0.15 mg i.v., both nares were inspected with a flexible fibreoptic endoscope (Olympus BF-P20D, Olympus, Tokyo, Japan). While one naris was chosen for intubation, oxygen was administered to the other nasal opening via a catheter. A flexible spiral tube (Rüscheli i.d. 7.0 mm for men, 6.5 mm for women; Rüsch, Waiblingen, Germany) was attached to the endoscope which was subsequently inserted through the chosen naris. The larynx and glottis were sprayed under fibreoptic vision through the biopsy channel with 5 mL 2% lignocaine, and 2 min later the trachea was sprayed with the same amount of lignocaine.
After topical analgesia was established and with the fibrescope positioned in the trachea, anaesthesia was induced with etomidate 0.2-0.3 mg kg−1. After loss of the eyelid reflex the tube was fibreoptically advanced through the nose into the trachea.
Anaesthesia was then maintained with 70% N2O in oxygen with enflurane.
Reaction of the nasal mucosa was classified as follows: 0 = no epistaxis, 1 = epistaxis during endoscopy, 2 = epistaxis during insertion of the nasotracheal tube, 3 = profuse epistaxis because of 1 and 2 resulting in a visible accumulation of blood in the oral part of the pharynx or the posterior pharyngeal wall (confirmed by laryngoscopy after conclusion of the investigation).
Pain was also assessed during transnasal endoscopy according to a verbal analogue scale which had been explained to the patient on the day prior to surgery: 0 = no pain, 1 = mild pain, 2 = moderate pain, 3 = severe pain.
Heart rate, systolic, diastolic and mean arterial pressure were recorded 5 min after a rest period (control), 3 and 6 min after nasal application of the solution, immediately after intubation, 5 and 10 min later. SpO2 and ST-segment analysis of ECG leads II and V5 were continuously performed (Siemens Siredoc 1280, Siemens, Erlangen, Germany) (0 = no change, 1 = horizontal depression >0.1 mV, 2 = descending depression >0.1 mV, 3 = other observations, all events over a minimum of 10 consecutive heart actions).
Statistical evaluation of the haemodynamic data used the Wilcoxon rank sum test at a level of significance of P<0.05.
The two treatment groups were comparable with regard to demographic data (Table 1).
There was no difference in the intensity of pain during endoscopy between the groups (Table 2).
Epistaxis was observed in five patients in the cocaine group, while profuse epistaxis occurred in one patient in the phenylephrine/lignocaine group (not significant) (Table 3).
Blood pressure and heart rate were not significantly different (P=0.36) between the groups throughout the study (Table 4).
A horizontal ST-segment depression was observed at different measurement points in three patients in the group receiving cocaine and in two patients in the phenylephrine/lignocaine group; there were no differences between groups (Table 5).
Intubation could be performed in all patients without difficulty.
Awake nasal fibreoptic intubation has been used increasingly over the past few years. It is indicated when direct laryngoscopy is precluded, in patients with anomalies of the upper airways, larynx or trachea and in patients who require an endoscopic investigation prior to tracheal intubation .
Cocaine abuse is associated with serious negative side effects [7-11]. This questions the safety of cocaine used under clinically controlled conditions, particularly in combination with lignocaine, which has been shown in animals to potentiate cocaine toxicity .
The low incidence of pain in the two treatment groups during endoscopy confirms the similarity in the effect of both substances.
With regard to the incidence of epistaxis, the results confirm those of other authors [13,14]. They did not find differences between patients who received topically vasoactive drugs or placebo. This is of particular interest since the vasoconstrictive effect of vasoactive substances was confirmed by computerized tomography . Furthermore, the pneumotachographically measured resistance of the nares was significantly reduced following the application of lignocaine/phenylephrine as well as after cocaine .
Despite pronounced nasal vasoconstriction, a marked increase in the plasma concentration of cocaine can occur following topical administration [17,18]. Resnik et al. reported the onset of acute systemic effects within 2 min and peak effects after 15-20 min independent of the cocaine plasma concentration.
Cocaine increases the concentration of noradrenaline at the receptor level, thus inducing tachycardia, rise in blood pressure, coronary vasoconstriction, and has lead to myocardial infarction .
Phenylephrine mainly acts directly on alpha-receptors. The cardiovascular effects consist of a rise in blood pressure and reflex bradycardia may occur . In animals, phenylephrine produces coronary vaso-constriction .
The patients reported here did not show the significant rise in heart rate or blood pressure reported elsewhere . Other authors  found different results, maybe because of the absence of topical analgesia of larynx, glottis and trachea. The systemic effects of lignocaine after absorption may have contributed to an increase in the depth of anaesthesia .
Lange et al. failed to demonstrate electrocardiographic signs of myocardial ischaemia even with a decreased diameter of the coronary arteries following nasal cocaine. In the present study, transient alterations in the ST-segment were observed in four patients. These ceased spontaneously without any pharmacological intervention and in the post-operative period no patient showed signs or symptoms of myocardial ischaemia.
The authors suggest that the mixture of phenylephrine and lignocaine is a suitable alternative to cocaine for nasal fibreoptic intubation.
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