To the Editor:- Bleeding is a troublesome complication of nasotracheal intubation that can both promote laryngospasm and impair subsequent attempts at laryngoscopy. Even when preventive measures are used (oxymetazoline nasal drops, tube lubrication, smaller tubes) bleeding complications can occur. In a prospective study, a “globule” of tissue was present on the tube tip in 33 of 100 patients after nasotracheal intubation. [1]More dramatic reports such as avulsion of the turbinate [2]or retropharyngeal dissection [3]have been described.

Local practice at our hospital is a simple modification of the technique for nasotracheal intubation that may decrease the incidence of bleeding. An entire red rubber catheter (size 10 - 12 French for pediatric patients) is fitted over the end of the nasotracheal tube before its advancement, by placing the end of the endotracheal tube into the flared end of the catheter. This presents a smooth noncutting surface to the nasal mucosa as the tube-catheter combination is advanced. Using direct laryngoscopy and a McGill's forceps, the catheter is removed in the oropharynx before final advancement of the nasotracheal tube. This technique is simpler to perform than a previously suggested technique in which orotracheal intubation precedes the nasotracheal catheter-tube combination. [4]This technique is also simpler and cheaper than serial dilations with nasal trumpets [5]and avoids the risk of losing a small foreign body in the airway when a finger glove is used to cover the tube tip. [6] 

Tom Elwood

Acting Assistant Professor

Sally Parker

Acting Assistant Professor

Chandra Ramamoorthy

Associate Professor; Department of Anesthesiology and Critical Care Medicine; Seattle, Washington

(Accepted for publication April 24, 1998.)

Harvey DC, Amorosa P: Traumatic nasotracheal intubation (letter). Anaesthesia 1986; 41(4):442
Scamman FL, Babin RW: An unusual complication of nasotracheal intubation. Anesthesiology 1983; 59(4):352-3
Daly WM: Unusual complication of nasal intubation: Report of a case. Anesthesiology 1953; 14:96
Becker DW Jr, Bass CB, Williams VL: An aid to nasotracheal intubation in orthognathic surgery. Cleft Palate Craniofac J 1993; 30(3):350
Wehner RJ: Anesthesia for oral surgery. J Am Assoc Nurse Anesthetists 1984; 52:619-25
Wright PJ: Nasotracheal intubation: Another approach (letter). Anaesthesia 1986; 41(10):1057-8