To the Editor:—

May I comment about the case report on a complication of nasal intubation by Andrea R. Williams et al.  on page 1782 in the June 1999 issue of Anesthesiology. 1This report describes an accidental middle turbinectomy during a nasal tracheal intubation. The authors note that lack of topical vasoconstriction may have contributed to the injury. There is another factor that should be considered before nasal intubation. In a large proportion of such patients, one nasal passage is smaller than the other. Thus, there is a 50% chance of inserting a nasal trachea tube in the narrower of the two. Having the patient sniff and inspection of the nares will not always reveal the narrower of the two passages. There is a maneuver performed before nasal intubation that could shrink the mucous membrane as well as reveal the narrower of the two passages. It was taught to the anesthesia staff at Grasslands Hospital in Westchester, New York by our chief, Harold Bishop in the 1960s. I don’t think he claimed originality.

Two 6-inch cotton-tipped applicator sticks were dipped in neosynephrine (cocaine if an awake intubation was planned). Each cotton tipped stick was slid posterior along the floor of the nose. The mucosa was shrunk and palpation clearly revealed which passage was more patent. Obviously a wider passage will make an easier intubation with fewer complications.

Williams AR, Burt N, Warren T. Accidental middle turbinectomy: A complication of nasal intubation. A nesthesiology 1999; 90:1782–84