Possible association between successful intubation via the right nostril and anatomical variations of the nasopharynx during nasotracheal intubation: a multiplanar imaging study

Nasopharynx evaluation in children of unilateral cleft palate patients and normal with cone beam computed tomography

OBJECTIVE

This study aimed to examine the morphological characteristics of the nasopharynx in unilateral Cleft lip/palate (CL/P) children and non-cleft children using cone beam computed tomography (CBCT).

METHODS

A retrospective study consisted of 54 patients, of which 27 patients were unilateral CL/P, remaining 27 patients have no CL/P. Eustachian tubes orifice (ET), Rosenmuller fossa (RF) depth, presence of pharyngeal bursa (PB), the distance of posterior nasal spine (PNS)-pharynx posterior wall were quantitatively evaluated.

RESULTS

The main effect of the CL/P groups was found to be effective on RF depth-right (p < 0.001) and RF depth-left (p < 0.001). The interaction effect of gender and CL/P groups was not influential on measurements. The cleft-side main effect was found to be effective on RF depth-left (p < 0.001) and RF depth-right (p  =  0002). There was no statistically significant relationship between CL/P groups and the presence of bursa pharyngea.

CONCLUSIONS

Because it is the most common site of nasopharyngeal carcinoma (NPC), the anatomy of the nasopharynx should be well known in the early diagnosis of NPC.

Usefulness of lateral cephalometric radiography for successful blind nasal intubation: a prospective study

Background

This study aimed to investigate the relationship between pharyngeal morphology and the success or failure of blind nasotracheal intubation using standard lateral cephalometric radiography and to analyze the measurement items affecting the difficulty of blind nasotracheal intubation.

Methods

Assuming a line perpendicular to the Frankfort horizontal (FH) plane, the reference point (O) was selected 1 cm above the posterior-most end of the hard palate. A line passing through the reference point and parallel to the FH plane is defined as the X-axis, and a line passing through the reference point and perpendicular to the X-axis is defined as the Y-axis. The shortest length between the tip of the uvula and posterior pharyngeal wall (AW), shortest length between the base of the tongue and posterior pharyngeal wall (BW), and width of the glottis (CW) were measured. The midpoints of the lines representing each width are defined as points A, B, and C, and the X and Y coordinates of each point are obtained (AX, BX, CX, AY, BY, and CY). For each measurement, a t-test was performed to compare the tracheal intubation success and failure groups. A binomial logistic regression analysis was performed using clinically relevant items.

Results

The items significantly affecting the success rate of blind nasotracheal intubation included the difference in X coordinates at points A and C (Odds ratio, 0.714; P-value, 0.024) and the ∠ABC (Odds ratio, 1.178; P-value, 0.016).

Conclusion

Using binomial logistic regression analysis, we observed statistically significant differences in AX-CX and ∠ABC between the success group and the failure group.

Impact of choice of nostril on nasotracheal intubation when using video rigid stylet: a randomized clinical trial

BACKGROUND

Patients undergoing oral and maxillofacial surgeries under general anesthesia usually require nasotracheal intubation. When presented with patients with equally patent nostrils, selection of the nostril to use for intubation is an important decision for facilitating intubation. The objective of this trial is to determine whether choice of nostril impacts nasotracheal intubation when using a video rigid stylet in patients undergoing oral and maxillofacial surgery.

METHODS

Fifty patients scheduled for elective oral and maxillofacial surgery requiring nasotracheal intubation were randomly allocated into two groups to undergo nasotracheal intubation through the left nostril (Group L, n = 25) or the right nostril (Group R, n = 25). Intubation was performed by experienced anesthesiologists using a video rigid stylet. The primary endpoint was time to successful intubation, which was defined as the duration from when the tip of the stylet-tube assembly entered the selected nostril to when the tube entered the trachea. Secondary outcomes included: length of time for device insertion; length of time for tube insertion; total success rate; first-attempt success rate; number of intubation attempts; requirement of airway assisted maneuvers; incidence and severity of epistaxis. Intubation-related adverse events were monitored for up to postoperative 24 h.

RESULTS

Median time (interquartile range) to tracheal intubation was 25.3 seconds (20.7 to 27.6) in Group L and 26.8 seconds (22.5 to 30.0) in Group R (median difference (MD) = 1.9; 95% confidence interval (CI) -1.8 to 5.7, P = 0.248). Nasotracheal intubation was successful in all patients in both groups and the first-attempt success rates in both groups were similar (Group L: 96% (24/25); Group R: 96% (24/25); relative risk (RR) 1.0; 95% CI 0.9 to 1.1; P > 0.999). No significant difference of requirement of assisted maneuvers was noted between the two groups (Group L: 36% (9/25); Group R: 28% (7/25); RR 0.8; 95% CI 0.3-1.8; P = 0.544). Furthermore, all patients showed a high quality of visualization of the glottis (Cormack and Lehane Grade I). For safety outcomes, the incidence and severity of epistaxis during intubation was comparable between the two groups. There were no significant differences between the selection of nostrils and intubation-related adverse events up to 24 h after surgery.

CONCLUSIONS

When considering which nostril to use for intubation with video rigid stylet, either nostril can be used similarly.

TRIAL REGISTRATION

Clinicaltrials.gov . Identifier: NCT05218590.

Spur-of-the-Moment: An Exacting Nasal Intubation

Nasotracheal intubations are an important airway management technique in otolaryngologic surgeries and trauma distorting oropharyngeal structures. For those performing these procedures, nasal deformities are not uncommon. This case report highlights an example of recurrent cuff tears that occurred during nasotracheal intubation of a patient with an unknown nasal bone spur. A careful airway analysis with available imaging studies may predict the potential difficulty with nasotracheal intubation. A successful approach to nasotracheal intubation can then be attempted on the contralateral side if a nasal bone spur is present.

Radıologıcal Evaluatıon of the Recesses on the Posterıor Wall of the Nasopharynx wıth Cone-beam Computed Tomography

Background

The posterior wall of the nasopharynx is composed of loose connective tissue that includes many important anatomical structures. Various structures, such as the opening of the Eustachian tube (ET), the Rosenmüller fossa (RF), and the pharyngeal bursa (PB) are found here.

Aim

To evaluate the nasopharynx posterior wall anatomic structures, including the Eustachian tube, Rosenmüller fossa, and pharyngeal bursa with cone-beam computed tomography.

Materials and Methods

The depth, width, and length of the Eustachian tube, Rosenmüller fossa, and pharyngeal bursa were measured in 150 patients using axial-sagittal cone-beam computed tomography. The Eustachian tube and Rosenmüller fossa distance to the midsagittal plane, the coronal region passing through the posterior end of the nasal septum, the superior-inferior extremity of the recesses, and the nasal floor plane distance were measured. The relationship between Rosenmüller fossa types and other parameters were evaluated.

Results

The incidence of right Rosenmüller fossa types 1, 2, and 3 were 16%, 18%, and 66%, respectively, and that of the left Rosenmüller fossa types 1, 2, and 3 were 16%, 19.3%, and 64.7%, respectively. The mean pharyngeal bursa width, length, and depth were 10.8, 5.7, and 4.0 mm, respectively; those of the Eustachian tube were 5.6, 7.1, and 7.3 m, respectively; those of the right Rosenmüller fossa were 4.0, 12.4, and 10.5 mm, respectively; and those of the left Rosenmüller fossa were 3.8, 12.5, and 10.9 mm, respectively.

Conclusions

The posterior wall of the nasopharynx contains several important anatomical structures. Evaluation of these using cone-beam computed tomography has many clinical and radiological advantages. To understand and interpret the coincidental findings in CBCT, dental radiologists should have access to more detailed information concerning the anatomy of the nasopharynx.

Maxillary sinusitis developed as sequelae of accidental middle turbinectomy that occurred during nasotracheal intubation: a case report

BACKGROUND

Nasotracheal intubation is a very useful technique for orofacial or dental surgery. However, the technique itself can be more traumatic than that of orotracheal intubation. Complications such as turbinectomy or bleeding are often reported. However, little is known about the follow-up of patients after these complications.

CASE PRESENTATION

The present case describes an accidental middle turbinectomy that led to endotracheal tube obstruction during nasotracheal intubation, and discusses its long-term follow-up. A 19-year-old man underwent mandibular surgery under general anesthesia and nasotracheal intubation. His right middle turbinate was completely avulsed and became firmly occluded within the tube during nasotracheal intubation. The nasotracheal intubation was performed again and the operation was completed safely. The patient was discharged without sequelae after postoperative care. However, he had symptoms of nasal obstruction and sleep disturbance for 3 months postoperatively. Synechiae were detected between the nasal septum and lateral nasal wall on a right rhinoscopic examination and facial computed tomography at 3 months postoperatively. Additionally, he showed ipsilateral maxillary sinusitis on facial computed tomography at the 2-year follow-up examination.

CONCLUSIONS

Nasotracheal intubation can cause late complications as well as early complications. Therefore, if nasotracheal intubation is to be performed, the anesthesiologist should identify the nasal anatomy of the patient accurately and prepare appropriately. In addition, if complications occur, follow-up observation should be performed.

Evaluation of the pharyngeal recess with cone-beam computed tomography

PURPOSE

To evaluate the radiological anatomy of the pharyngeal recess (PR) by gender and age.

METHODS

Images of patients who underwent cone-beam computed tomography (CBCT) were analyzed retrospectively. A total of 600 PRs (140 male, 160 female) were examined. PR depths, distances between the posterior nasal spine (PNS) and the posterior wall of the pharynx, right and left torus levatorius lengths, and distances between the right and left torus levatorius were measured on the axial plane passing through the PNS-basion point.

RESULTS

PR depths differed significantly between age groups (right p = 0.030, left p = 0.047). The PR depths of individuals under 35 years of age were significantly higher than those of individuals aged 35 and over. Further, the distances between the PNS and the posterior wall of the pharynx differed significantly between age groups and between gender groups. The distances between the PNS and the posterior wall of the pharynx were shorter in patients under 35 years of age (p = 0.000). In terms of gender, these distances were significantly longer in males (p = 0.014). The distances between the right and left torus levatorius were also significantly longer in males (p = 0.029).

CONCLUSION

The PR is the region in which nasopharyngeal carcinoma originates most frequently and is very important for early diagnosis. The present results indicated that this region can be examined with CBCT.

Thermophysical Properties of Thermosoftening Nasotracheal Tubes

Thermosoftening treatment of polyvinyl chloride (PVC) nasotracheal tubes (NTTs) can reduce the incidence and amount of epistaxis during nasotracheal intubation. The optimal thermal setting for thermosoftening treatment of NTTs without burn injury was investigated. Two composite types of PVC NTTs were used. Following withdrawal of the PVC NTTs from a bottle of water at 45 or 60°C, the changes in the surface temperature of the NTTs were measured by infrared thermography. Hardness of the NTTs at 25, 30, 35, and 40°C was measured. The incidence of epistaxis during nasotracheal intubation using thermosoftened NTTs was evaluated retrospectively. The surface temperature of both PVC NTTs dipped in 45 and 60°C water decreased to below body temperature 30 seconds after withdrawing them from the bottles. Although thermosoftening treatment proportionally decreased the hardness of both types of NTTs, the degrees differed according to their composition. When avoiding impingement of the NTT on the posterior wall of the nasopharynx, the incidence of mild and moderate epistaxis was 2.3%. Flexibility of PVC NTTs could be obtained by thermosoftening treatment at 60°C without burn injury. Thermosoftening treatment of PVC NTTs may be useful to avoid epistaxis during nasotracheal intubation.

A comparison between the Disposcope endoscope and fibreoptic bronchoscope for nasotracheal intubation: a randomized controlled trial

Background

Nasotracheal intubation (NTI) is frequently performed for oral and maxillofacial surgeries. This study evaluated whether NTI is easier when guided by Disposcope endoscopy or fibreoptic bronchoscopy.

Methods

Sixty patients (30 per group) requiring NTI were randomly assigned to undergo fibreoptic bronchoscopy-guided (fibreoptic group) or Disposcope endoscope-guided (Disposcope group) NTI. The NTI time, which was defined as the time from when the fibreoptic bronchoscope or aseptic suction catheter was inserted into the nasal cavity to the time at which the tracheal tube was correctly inserted through the glottis, was recorded. Epistaxis was evaluated by direct laryngoscopy five minutes after completing NTI and was scored as one of four grades according to the following modified criteria: no epistaxis, mild epistaxis, moderate epistaxis, and severe epistaxis.

Results

The time to complete NTI was significantly longer in the fibreoptic group than in the Disposcope group (38.4 s vs 24.1 s; mean difference, 14.2 s; 95% confidence interval (CI), 10.4 to 18.1). Mild epistaxis was observed in 8 patients in the fibreoptic group and in 7 patients in the Disposcope group (26.7% vs 23.3%, respectively; relative risk, 1.2; 95% CI, 0.4 to 3.9), though no moderate or severe epistaxis occurred in either group. Furthermore, no obvious nasal pain was reported by any of the patients at any time point after extubation (P = 0.74).

Conclusion

NTI can be completed successfully using either fibreoptic bronchoscopy or Disposcope endoscope as a guide without any severe complications. However, compared to fibreoptic bronchoscopy, Disposcope endoscope requires less execution time (the NTI time).

Trial registration

This clinical research was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn, ChiCTR-IPR-17011462, date of registration, May 2017).

Which nostril should be used for nasotracheal intubation with Airtraq NT®: the right or left? A randomized clinical trial

Background/aim

Nasotracheal Airtraq is specifically designed to improve the glottis view and ease the nasotracheal intubation process in normal and difficult cases.

Materials and methods

After Ethics committee approval, we decided to enroll 40 patients with an ASA physical status of I or II, between 18 and 70 years of age undergoing elective maxillofascial, oral, and double chin surgery to determine which nostril is more suitable for nasotracheal intubation with nasotracheal Airtraq. Patients were randomized into the right and left nostril groups.

Results

Demographic and airway characteristics were similar among the groups. Nasotracheal intubation through the right nostril was shorter than that of the left nostril during nasotracheal intubation with the Airtraq NT (P < 0.001). 90° counterclockwise rotation of the tip of the tube was needed for directing the tube into the vocal cords in both right and left nostril groups (72% vs 88%). External laryngeal pressure and head flexion maneuvers can ease the intubation from the left nostril (P < 0.001 vs P = 0.03). Cuff inflation maneuver also can be helpful in some cases. We did not need any operator change or Magill forceps for any of the patients.

Conclusion

Nasotracheal intubation via the right nostril can be safely and quickly performed with the Airtraq NT without the need of Magill forceps. We recommend the use of the 90° counterclockwise rotation, external laryngeal pressure, and head flexion maneuvers to direct the tube into the vocal cords first. On the other hand, cuff inflation maneuver must also be kept in mind.