To the Editor:—
Despite Williams et al. not being aware of an unintentional middle turbinectomy occurring during nasotracheal intubation, 1it has been reported and discussed—albeit not with a 6.0 cuffed RAE endotracheal tube (Mallinckrodt Medical, St. Louis, MO)—in Anesthesiology. 2,3
I am particularly interested in the details of how the RAE was inserted from the nares into the nasopharynx. Williams et al. stated it was inserted “into the patient’s right nares with the bevel of the tube facing medially.” This is a bit ambiguous. Is the bevel the point or flat part (opening at the end of the RAE)? What was the opening “facing medial to”— the nasal septum or the turbinates? Was it inserted with the anesthesiologist standing or sitting cephalad to the patient’s head? Lastly, but in all probability most important, was the RAE pulled cephalad at its acute angle (16–17.5 cm markings) after being inserted into the nares and while being passed into the nasopharynx?
Regardless of the type of nasotracheal tube used, turbinectomy is an avoidable complication if: (1) before anesthesia, the turbinates are shrunk using cocaine (4–10%) or a lidocaine-phenylephrine mixture 4,5; (2) when inserting the tube into the nares, its tip lies alongside (parallel) to the nasal septum with the opening in the bevel facing the turbinates, and (3) maintaining this position, it is pulled cephalad as it is passed posteriorly into the nasopharynx. Pulling the nasotracheal
tube cephalad (fig. 1),
more likely than not directs its bevel and tip away from the turbinates and promotes their passing between the inferior turbinate and the nasal surface of the palate where the nasal passage is the largest. This, in itself, avoids turbinectomy even with a REA tube which if not pulled cephalad is likely to be directed at the turbinates.