Adjunctive Maneuvers for Glottic Entry During Pediatric Nasotracheal Intubation: A Prospective Observational Cohort Study

Background/Objectives: Pediatric nasotracheal intubation may remain difficult at the stage of glottic alignment and laryngeal entry even after passage through the nasal cavity. We aimed to describe the distribution of adjunctive maneuvers required for glottic entry during pediatric nasotracheal intubation and to explore factors associated with their use. Methods: We conducted a prospective observational cohort study of 54 children undergoing dental surgery requiring nasotracheal intubation. Glottic-entry maneuvers were categorized as direct passage, cuff inflation assistance, or Magill forceps assistance. Baseline characteristics, perioperative variables, tube size selection, tube downsizing, and bleeding grade were compared among groups. Univariable and multivariable logistic regression analyses were performed for the primary outcome, defined as the need for any adjunctive maneuver. Results: Glottic entry was achieved by direct passage in 34 patients, required cuff inflation assistance in 15, and required Magill forceps assistance in 5. Baseline characteristics were broadly similar across groups, although sex distribution, body weight, and preoperative respiratory rate differed significantly. Anesthesia duration, surgery duration, bleeding grade, initial tube size, tube downsizing, and final tube size did not differ significantly among groups. In univariable logistic regression, female sex showed a borderline association with the need for any adjunctive maneuver, whereas age and initial tube size were not significant. In multivariable analysis, no stable independent predictor was identified. Conclusions: Most children achieved glottic entry by direct passage, whereas a minority required cuff inflation assistance or Magill forceps assistance. These prospective data provide a practical stepwise description of glottic-entry assistance during pediatric nasotracheal intubation.