To the Editor:-Recently, several authors have advocated the use of a lighted stylet to facilitate either awake intubation or an unanticipated difficult intubation. [1–3] During direct laryngoscopy, the lighted stylet can improve the view in the hypopharynx, and transillumination can assist in guiding the endotracheal tube into the trachea.
We have had success in patients with unanticipated difficult intubation with a modification of this technique. Based on a previous report using the LTA kit (Abbott Laboratories, North Chicago, IL),  we thread a lighted stylet (Tube Stat, Concept, Clearwater, FL) through the Murphy hole of an endotracheal tube (Figure 1). Using this configuration, the endotracheal tube does not obstruct the view while the end of the lighted stylet is placed in the trachea. Also, traumatic complications may be less likely to occur. [5,6] The lighted stylet threaded through the Murphy hole is more maneuverable, and the light is not attenuated by the surrounding endotracheal tube. Once the tip of the lighted stylet is placed in the trachea, the endotracheal tube can be threaded down over the tip of the stylet into the trachea. With the stylet passing through the Murphy hole, if difficulty is encountered because of the alignment of the curved (hockey stick) stylet and the trachea, the endotracheal tube can be gently rotated 180 degrees to improve alignment and ease the passage of the endotracheal tube into the trachea.
Jerry W. Biehl, C.R.N.A.
Denis L. Bourke, M.D.
Baltimore Veterans Affairs Medical Center; Anesthesiology Service
10 North Greene Street; Baltimore, Maryland 21201–1566
(Accepted for publication February 5, 1997.)