Nasogastric Tube-guided Nasotracheal Intubation for Narrow Nasal Passage in Orthognathic Surgery

INTRODUCTION Nasotracheal intubation is an essential procedure in orthognathic surgery. However, nasotracheal intubation is difficult in patients with a narrow nasal passage because the tracheal tube cannot pass through the passage. Dentofacial deformities might be concomitant with a narrow nasal passage and nasal septum deviation because the nasal cavity correlates with craniofacial structures. The management of difficult nasotracheal intubation is reported.1–3 However, it is focused on the difficult airway at the oropharynx. The management of difficult intubation at the nasal cavity due to a narrow nasal passage is little known.3 In this study, a nasotracheal intubation technique in a dentofacial deformity with a narrow nasal passage is reported. TECHNICAL NOTE A 28-year-old man presented with skeletal class II malocclusion with maxillary vertical excess. Nasotracheal intubation was necessary to perform Le Fort I and bilateral sagittal split osteotomy. Computed tomography showed a narrow nasal passage and nasal septum deviation (Fig. 1). Nasogastric tube-guided nasotracheal intubation was performed (Fig. 2) because a nasotracheal tube with a diameter of 6.5 mm could not pass through the nasal passage by conventional technique.Fig. 1.: A 28-year-old man presented with skeletal class II malocclusion with maxillary vertical excess and high mandibular plane angle. Coronal computed tomography revealed a narrow nasal passage and septum deviation.Fig. 2.: Schematic diagram of the nasogastric tube-guided nasotracheal intubation. (1) The nasogastric tube was inserted into the preformed nasotracheal tube, and the tip of the nasogastric tube was exposed from the tracheal tube. (2) The tip of the nasogastric tube was inserted into the nostrils through the nasal passage. (3) The tip of the nasogastric tube was pulled out of the oral cavity, using Magill forceps. (4) A nasotracheal tube was inserted from the nostrils to the oropharynx using the guide. The nasogastric tube was removed from the nasal tracheal tube. (5) Finally, a nasotracheal tube was inserted into the trachea using a conventional procedure. (1) The 16 Fr nasogastric tube (Hoyu Medical) was inserted into the preformed nasotracheal tube with a diameter of 7.0 mm (Smith Medical), and the tip of the nasogastric tube was exposed from the tracheal tube. (2) The tip of the nasogastric tube was inserted into the nostrils through the nasal passage. (3) The tip of the nasogastric tube was pulled out of the oral cavity using Magill forceps to make it easier to use as a guide. The nasogastric tube was guided from the nostrils to the oropharynx via the nasal passage and nasopharynx. (4) A nasotracheal tube was inserted from the nostrils to the oropharynx using the guide (Fig. 2). The nasogastric tube was removed from the nasotracheal tube. (5) Finally, a nasotracheal tube was inserted into the trachea using a conventional procedure. DISCUSSION Fiberoptic intubation is the gold standard for difficult airways. However, this method is expensive and requires training. The tube-guided nasotracheal intubation technique has been reported to be safe and cost-effective for difficult airways, including the use of a suction catheter or nasogastric tube as a guide.1–3 It is well known that mandibular retrusion and small mandible induce difficult intubation due to narrow oropharynx. However, difficult intubation at the nasal passage has rarely been reported.3 A long face and dolichofacial pattern might show a difficult nasal intubation because it may have a narrow nasal passage due to the narrow V-shaped maxillary arch and a high palatal vault.4,5 Moreover, concomitant with nasal septum deviation was a more complicated nasal passage. It might result in a difficult intubation, and induced nasal soft tissue injury and epistaxis. The nasogastric tube-guided nasotracheal intubation could pass through the narrow nasal passage. Although the potential complications of this technique are soft tissue injury and epistaxis, a randomized controlled trial revealed that this technique reduces the incidence and severity of epistaxis and requires fewer manipulations than the conventional technique.1 This technique could contribute not only to difficult intubation at the oropharynx but also at the nasal passage in dentofacial deformities. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.