Which nostril should be used for nasotracheal intubation: the right or left? A randomized clinical trial

3M microfoam™ surgical tape prevents nasal pressure injury associated with nasotracheal intubation: A randomized double-blind trial

BACKGROUND

3M microfoam™ surgical tape (3ST: 3M Japan Limited) is used for pressure wound control of medical equipment. It is cushioned and can be fitted to any body part. Here we investigated whether 3ST prevents nasal pressure injury associated with nasotracheal intubation (NTI).

METHODS

We conducted a prospective, randomized double-blind study, enrolling 63 patients aged 20 to 70 years, who underwent general anesthesia with NTI. They were divided into 2 groups; those treated with 3ST (group S; n = 31) and control (group C; n = 31). After NTI and before securing the nasotracheal tube, a 35 × 25 mm 3ST was used to protect the nasal wing in group S, and the nasotracheal tube was fixed in place after NTI without protection in group C. The primary outcome was the presence or absence of nasal pressure injury after extubation. The Chi-Square test was used to assess the association between the 2 categorical variables.

RESULTS

Nasal pressure injury was observed in 7 and 19 patients from groups S and C, respectively, representing a significant difference between the 2 groups (24.1% vs 67.8%, P = .001). Remarkably, none of the patients developed ulcers.

CONCLUSION

3ST prevents nasal pressure injury associated with NTI.

Nasopharynx evaluation in children of unilateral cleft palate patients and normal with cone beam computed tomography

OBJECTIVE

This study aimed to examine the morphological characteristics of the nasopharynx in unilateral Cleft lip/palate (CL/P) children and non-cleft children using cone beam computed tomography (CBCT).

METHODS

A retrospective study consisted of 54 patients, of which 27 patients were unilateral CL/P, remaining 27 patients have no CL/P. Eustachian tubes orifice (ET), Rosenmuller fossa (RF) depth, presence of pharyngeal bursa (PB), the distance of posterior nasal spine (PNS)-pharynx posterior wall were quantitatively evaluated.

RESULTS

The main effect of the CL/P groups was found to be effective on RF depth-right (p < 0.001) and RF depth-left (p < 0.001). The interaction effect of gender and CL/P groups was not influential on measurements. The cleft-side main effect was found to be effective on RF depth-left (p < 0.001) and RF depth-right (p  =  0002). There was no statistically significant relationship between CL/P groups and the presence of bursa pharyngea.

CONCLUSIONS

Because it is the most common site of nasopharyngeal carcinoma (NPC), the anatomy of the nasopharynx should be well known in the early diagnosis of NPC.

Impact of choice of nostril on nasotracheal intubation when using video rigid stylet: a randomized clinical trial

BACKGROUND

Patients undergoing oral and maxillofacial surgeries under general anesthesia usually require nasotracheal intubation. When presented with patients with equally patent nostrils, selection of the nostril to use for intubation is an important decision for facilitating intubation. The objective of this trial is to determine whether choice of nostril impacts nasotracheal intubation when using a video rigid stylet in patients undergoing oral and maxillofacial surgery.

METHODS

Fifty patients scheduled for elective oral and maxillofacial surgery requiring nasotracheal intubation were randomly allocated into two groups to undergo nasotracheal intubation through the left nostril (Group L, n = 25) or the right nostril (Group R, n = 25). Intubation was performed by experienced anesthesiologists using a video rigid stylet. The primary endpoint was time to successful intubation, which was defined as the duration from when the tip of the stylet-tube assembly entered the selected nostril to when the tube entered the trachea. Secondary outcomes included: length of time for device insertion; length of time for tube insertion; total success rate; first-attempt success rate; number of intubation attempts; requirement of airway assisted maneuvers; incidence and severity of epistaxis. Intubation-related adverse events were monitored for up to postoperative 24 h.

RESULTS

Median time (interquartile range) to tracheal intubation was 25.3 seconds (20.7 to 27.6) in Group L and 26.8 seconds (22.5 to 30.0) in Group R (median difference (MD) = 1.9; 95% confidence interval (CI) -1.8 to 5.7, P = 0.248). Nasotracheal intubation was successful in all patients in both groups and the first-attempt success rates in both groups were similar (Group L: 96% (24/25); Group R: 96% (24/25); relative risk (RR) 1.0; 95% CI 0.9 to 1.1; P > 0.999). No significant difference of requirement of assisted maneuvers was noted between the two groups (Group L: 36% (9/25); Group R: 28% (7/25); RR 0.8; 95% CI 0.3-1.8; P = 0.544). Furthermore, all patients showed a high quality of visualization of the glottis (Cormack and Lehane Grade I). For safety outcomes, the incidence and severity of epistaxis during intubation was comparable between the two groups. There were no significant differences between the selection of nostrils and intubation-related adverse events up to 24 h after surgery.

CONCLUSIONS

When considering which nostril to use for intubation with video rigid stylet, either nostril can be used similarly.

TRIAL REGISTRATION

Clinicaltrials.gov . Identifier: NCT05218590.

Using of panoramic and posteroanterior cephalometric radiographs to identify the optimal nasal passage for nasotracheal intubation

Background and Aim

Selecting the optimum nasal passage for nasotracheal intubation is quite important in the maxillofacial surgeries for the success of intubation and the reduction of potential complications such as nasal mucosal laceration, epistaxis, avulsion of the inferior and middle turbinates, and septal laceration.

Materials and Methods

The present study evaluates standard panoramic radiographs (PR) and posteroanterior cephalometric radiographs (PACR) to determine the optimal nasal passage for nasotracheal intubation and compares the results with those of routine anesthesiological occlusion and spatula tests (ST). The results of occlusion tests (OT), ST, and radiological assessments of 60 patients prior to nasotracheal intubation were compared with the nasal endoscopic assessment results, and complications were evaluated.

Results

There was no significant association between the OT and nasal endoscopy results (P = 0.075). A significant association was found between the ST and nasal endoscopy results (P = 0.000), and between the radiological assessments and the nasal endoscopy results (P = 0.000). Compatibility with nasal endoscopy was 54% when the occlusion and ST were evaluated together, 75% when the OT and radiological assessments were evaluated together, and 86% when the ST and radiological assessments were evaluated together. The highest level of compatibility was 92% when all the tests were evaluated together.

Conclusion

The simple tests alone were found to be inadequate for the selection of the optimal nasal passage. Evaluation of PR and PACR, which are commonly used in maxillofacial surgeries, together with simple anesthesiological examination tests would increase nasotracheal intubation success and decrease complications.

For nasotracheal intubation, which nostril results in less epistaxis: right or left?: A systematic review and meta-analysis

BACKGROUND

Nasotracheal intubation is usually required in patients undergoing oromaxillofacial, otolaryngological or plastic surgery to prevent the airway encroaching into the operating field. Epistaxis is the most common complication, but which nostril is associated with a lower incidence and severity of epistaxis is still unclear.

OBJECTIVE

When both nostrils are patent, to determine the preferred nostril for nasotracheal intubation under general anaesthesia.

DESIGN

A systematic review and meta-analysis of randomised controlled trials (RCTs). The primary outcome was the incidence of epistaxis and the secondary outcomes included the incidence of severe epistaxis, the time required to pass the tube through the nasal passage and total intubation time.

DATA SOURCES

PubMed, Embase and the Cochrane Register of Controlled Trials were searched from database inception to 1 March 2020.

ELIGIBILITY CRITERIA

The only studies included were RCTs comparing epistaxis related to nasotracheal intubation via right or left nostril, in adult surgery patients undergoing general anaesthesia.

RESULTS

Ten RCTs with 1658 patients were included. Compared with the left nostril, intubation via the right nostril was associated with a significantly lower incidence of epistaxis: risk ratio (RR) and 95% confidence intervals (CI) were 0.78 (0.62 to 0.99), P = 0.04: a lower incidence of severe epistaxis (five studies, n=923), RR 0.40 (0.22 to 0.75), P = 0.004: and a shorter intubation time (three studies, n=345), mean difference -7.28 (-14.40 to -0.16) seconds, P = 0.05. In two studies (n=310), no significant difference between the right and left nostril was observed in the time to pass the tube through the nasal passages, mean difference -0.59 (-1.95 to 0.77) s, P = 0.40.

CONCLUSION

On the basis of the current available evidence, when both nostrils are patent, the right nostril is more appropriate for nasotracheal intubation, with a lower incidence and severity of epistaxis and faster intubation time.

TRIAL REGISTRATION

The study protocol has been registered in PROSPERO (CRD42020169949).

Comparison of hemostatic effect and safety between epinephrine and tramazoline during nasotracheal intubation: a double-blind randomized trial

Background

Nasal bleeding is the most common complication during nasotracheal intubation (NTI). To reduce nasal bleeding, the nasal mucosa is treated with vasoconstrictors (epinephrine [E] or tramazoline [T]) prior to NTI. This study aimed to determine whether E or T is more effective and safe for reducing nasal bleeding during NTI.

Methods

This study was preregistered on UMIN-CTR after being approved by the IRB of the School of Dentistry at Aichi Gakuin University. Written consent was received from all the patients. Total 206 patients aged 20–70 years and classified as 1–2 on American Society of Anesthesiologists-physical status were scheduled to undergo general anesthesia with NTI. At last, 197 patients were randomly divided into two groups and treated with either E (n = 99; 3 patients were discontinued) or T (n = 98; 2 patient were discontinued). After induction of general anesthesia, each patient’s nasal mucosa was treated using either E or T. The E used in this study was BOSMIN® SOLUTION 0.1% (Daiichi-Sankyo Co., Ltd., Tokyo), and the T used in this study was TRAMAZOLIN Nasal Solution 0.118% AFP, (Alfresa Pharma Corporation, Osaka). E was diluted five times according to the package insert (final concentration of E = 0.02%), and T was used in its original solution. After 2 min, NTI was performed via the right nostril. Primary outcome were the presence of nasal bleeding (if bleeding was recognized at the posterior pharyngeal wall via nasal cavity during intubation, it was defined as bleeding) and the degree of bleeding (classified as none, mild, moderate, or severe). Secondary outcomes were arrhythmia, and hemodynamic (mean atrial pressure and heart rate) changes associated with vasoconstrictors.

Results

The presence of bleeding was comparable in both groups (12.5%, E; 14.5%, T; P = 0.63). No significant difference between the groups regarding the degree of bleeding (P = 0.78) was observed, with most patients having no bleeding (n = 84, E; n = 82, T). No severe bleeding and no arrhythmias induced by vasoconstrictor were observed in the two groups.

Conclusions

Nasal treatment with E or T shows no difference in nasal bleeding during NTI. Although no arrhythmia associated with E was observed in this study, it has been reported in literature. Therefore, as frequency and degree of nasal bleeding were comparable, nasal treatment with T could reduce the risk of NTI.

Trial registration

UMIN-CTR (Registration No. UMIN000037907). Registered (05/09/2019).

Ephedrine pretreatment for nasotracheal intubation-related epistaxis in maxillofacial surgery with sufficient lubrication: A randomized clinical trial

WHAT IS KNOWN AND OBJECTIVE

Prior to nasotracheal intubation (NTI), topical nasal vasoconstrictors are used to prevent NTI-related epistaxis (NTIRE). Since we learned that there is no significant increase in NTIRE among hypertensive patients undergoing NTI with adequate lubrication but without vasoconstrictors, we initiated this randomized controlled study to assess the necessity of vasoconstrictor use in reducing NTIRE.

METHODS

Patients with the American Society of Anesthesiologists Physical Status Classification 1 and normal coagulation function, planned to undergo maxillofacial surgery with NTI were enrolled. Patients were randomly (1:1) assigned to each of the treatment groups: nasal treatment using pure oxybuprocaine gel with adequate lubrication (group G) or 1% ephedrine in addition to oxybuprocaine gel with adequate lubrication (group EG). In addition, the incidence and severity of NTIRE and intubation adjustments were studied.

RESULTS

A total of 844 patients, 429 and 415 (groups G and EG, respectively), were included in the analysis. No significant differences were observed in the NTIRE incidence rates in groups G (28%) and EG (27%; p = 0.75, relative risk [RR] = 0.95, 95% confidence interval [CI] 0.70-1.29). No significant differences in the NTIRE incidence rates between the two nostrils were observed in both groups (group G: left, 27.9% vs. right, 28% [p = 0.98, RR = 1.01, 95% CI 0.67-1.51]; group EG: left, 25.8% vs. right, 27.9% [p = 0.63, RR = 1.12, 95% CI 0.72-1.73]. No significant difference was observed in the severity of NTIRE (p = 0.74). In case of difficult advancement of the endotracheal tube, NTIRE incidence was 71% vs. 12% with smooth intubation (p < 0.01, RR = 18.33, 95% CI 12.55-26.77).

WHAT IS NEW AND CONCLUSION

Well-lubricated nasotracheal intubation does not require pretreatment with ephedrine to reduce NTIRE.

Comparison of the selection of nasotracheal tube diameter based on the patient's sex or size of the nasal airway: A prospective observational study

When selecting the nasotracheal tube diameter for nasotracheal intubation, atraumatic introduction of the tube through the nasal passage and a safe location of the tube's cuff and tip should be ensured simultaneously. To maintain safety margin for the tube's cuff and tip from the vocal cords and carina (2 cm and 3 cm, respectively), the maximum allowable proximal-cuff-to-tip distance was calculated as 5 cm less than the measured vocal cords-to-carina distance. The primary aim of this study was to find a single predictive preoperative factor of the nostril size and maximum allowable proximal-cuff-to-tip distance of nasotracheal tubes. The secondary aim was to compare the difference in the safety margin between the maximum allowable proximal-cuff-to-tip distance based on the patient's airway and the actual proximal-cuff-to-tip distance of the selected tube. We used fiberoptic bronchoscope to measure the distance from the vocal cords to the carina for the calculation of the maximum allowable proximal-cuff-to-tip distance. We analyzed the association of preoperative characteristics such as age, sex, height, and weight with the nostril size and maximum allowable proximal-cuff-to-tip distance. The proportion of patients with appropriate locations of both the cuff and tip was evaluated. Sex and height were significant predictive factors of the nostril size and maximum allowable proximal-cuff-to-tip distance, respectively (p = 0.0001 and p = 0.0048). The difference in the safety margin was significantly decreased when the tube diameter was selected based on the nostril size rather than by sex (p<0.0001). The proportion of patients who had the appropriate cuff/tip location was significantly larger (75.2%) when the tube diameter was selected by sex compared to when it was selected by the nostril size (65%) (p<0.0001). It is more suitable to select the nasotracheal tube diameter based on sex rather than by nostril size to ensure the safe location of the tube's cuff and tip simultaneously.

Comparison of disinfection effect between benzalkonium chloride and povidone iodine in nasotracheal intubation: a randomized trial

Background

Nasotracheal intubation can potentially result in microbial contamination from the upper respiratory tract to the lower respiratory tracts. However, an ideal nasotracheal disinfection method is yet to be determined. Therefore, we compared the disinfection effects between benzalkonium chloride and povidone iodine in nasotracheal intubation.

Methods

Overall, this study enrolled 53 patients aged 20–70 years who were classified into classes 1 and 2 as per American Society of Anesthesiologists-physical status and were scheduled to undergo general anesthesia with NTI. Patients who did not give consent (n = 2) and who has an allergy for BZK or PVI were excluded from the study. The patients were randomly divided into two groups on the basis of the disinfection method: BZK (n = 26, one patient was discontinued intervention) and PVI (n = 25). 50 patients were assessed finally.

The subjects’ nasal cavities were swabbed both before (A) and after disinfection (B), and the internal surface of the endotracheal tube was swabbed after extubation (C). The swabs were cultured on Brain heart infusion agar and Mannitol salt agar. The number of bacteria per swab was determined and the rates of change in bacterial count (B/A, C/B) were calculated. The growth inhibitory activity of the disinfectants on Staphylococcus aureus were also investigated in vitro.

Results

Although the initial disinfection effects (B/A) were inferior for benzalkonium chloride compared with those for povidone iodine, the effects were sustained for benzalkonium chloride (C/B). In the in vitro growth inhibitory assay against S. aureus, benzalkonium chloride showed higher inhibitory activity than povidone iodine.

Conclusion

Although both disinfectants were inactivated or diffused/diluted over time, benzalkonium chloride maintained the threshold concentration and displayed antimicrobial effects longer than povidone iodine; therefore, benzalkonium chloride appeared to show a better sustained effect. Benzalkonium chloride can be used for creating a hygienic nasotracheal intubation environment with sustained sterilizing effects.

Trial registration

UMIN-CTR (Registration No. UMIN000029645). Registered 21 Oct 2017.

A comparison between the Disposcope endoscope and fibreoptic bronchoscope for nasotracheal intubation: a randomized controlled trial

Background

Nasotracheal intubation (NTI) is frequently performed for oral and maxillofacial surgeries. This study evaluated whether NTI is easier when guided by Disposcope endoscopy or fibreoptic bronchoscopy.

Methods

Sixty patients (30 per group) requiring NTI were randomly assigned to undergo fibreoptic bronchoscopy-guided (fibreoptic group) or Disposcope endoscope-guided (Disposcope group) NTI. The NTI time, which was defined as the time from when the fibreoptic bronchoscope or aseptic suction catheter was inserted into the nasal cavity to the time at which the tracheal tube was correctly inserted through the glottis, was recorded. Epistaxis was evaluated by direct laryngoscopy five minutes after completing NTI and was scored as one of four grades according to the following modified criteria: no epistaxis, mild epistaxis, moderate epistaxis, and severe epistaxis.

Results

The time to complete NTI was significantly longer in the fibreoptic group than in the Disposcope group (38.4 s vs 24.1 s; mean difference, 14.2 s; 95% confidence interval (CI), 10.4 to 18.1). Mild epistaxis was observed in 8 patients in the fibreoptic group and in 7 patients in the Disposcope group (26.7% vs 23.3%, respectively; relative risk, 1.2; 95% CI, 0.4 to 3.9), though no moderate or severe epistaxis occurred in either group. Furthermore, no obvious nasal pain was reported by any of the patients at any time point after extubation (P = 0.74).

Conclusion

NTI can be completed successfully using either fibreoptic bronchoscopy or Disposcope endoscope as a guide without any severe complications. However, compared to fibreoptic bronchoscopy, Disposcope endoscope requires less execution time (the NTI time).

Trial registration

This clinical research was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn, ChiCTR-IPR-17011462, date of registration, May 2017).

Which nostril should be used for nasotracheal intubation with Airtraq NT®: the right or left? A randomized clinical trial

Background/aim

Nasotracheal Airtraq is specifically designed to improve the glottis view and ease the nasotracheal intubation process in normal and difficult cases.

Materials and methods

After Ethics committee approval, we decided to enroll 40 patients with an ASA physical status of I or II, between 18 and 70 years of age undergoing elective maxillofascial, oral, and double chin surgery to determine which nostril is more suitable for nasotracheal intubation with nasotracheal Airtraq. Patients were randomized into the right and left nostril groups.

Results

Demographic and airway characteristics were similar among the groups. Nasotracheal intubation through the right nostril was shorter than that of the left nostril during nasotracheal intubation with the Airtraq NT (P < 0.001). 90° counterclockwise rotation of the tip of the tube was needed for directing the tube into the vocal cords in both right and left nostril groups (72% vs 88%). External laryngeal pressure and head flexion maneuvers can ease the intubation from the left nostril (P < 0.001 vs P = 0.03). Cuff inflation maneuver also can be helpful in some cases. We did not need any operator change or Magill forceps for any of the patients.

Conclusion

Nasotracheal intubation via the right nostril can be safely and quickly performed with the Airtraq NT without the need of Magill forceps. We recommend the use of the 90° counterclockwise rotation, external laryngeal pressure, and head flexion maneuvers to direct the tube into the vocal cords first. On the other hand, cuff inflation maneuver must also be kept in mind.

Validation of Simple Methods to Select a Suitable Nostril for Nasotracheal Intubation

Background

Nasotracheal intubation is a blind procedure that may lead to complications; therefore, several tests were introduced to assess a suitable nostril for nasotracheal intubation. However, the value of simple tests in clinical practice was insufficient to evaluate.

Method

A diagnostic prospective study was conducted in 42 patients, ASA classes I–III, undergoing surgery requiring nasotracheal intubation for general anesthesia. Two simple methods for assessing the patency of nostrils were investigated. Firstly, the occlusion test was evaluated by asking for the patient's own assessment of nasal airflow during occlusion of each contralateral nostril while in a sitting posture. Secondly, patients breathed onto a spatula held 1 cm below the nostrils while in a sitting posture. All patients were assessed using these two simple tests. Nasal endoscopic examination of each patient was used as a gold standard.

Results

The diagnostic value of the occlusion test (sensitivity of 91.7%, specificity of 61.1%, PPV of 75.9%, NPV of 84.6%, LR+ of 2.36, and LR− of 0.14) seemed better than that of the spatula test (sensitivity of 95.8%, specificity of 25.0%, PPV of 63.0%, NPV of 81.8%, LR+ of 1.28, and LR− of 0.17). When both tests were combined in series, the diagnostic value increased (sensitivity of 87.9%, specificity of 70.8%, PPV of 80.1%, NPV of 81.4%, LR+ of 3.01, and LR− of 0.17).

Conclusion and Recommendations

The simple occlusion test is more useful than the spatula test. However, combining the results from both tests in series helped to improve the diagnostic value for selecting a suitable nostril for nasotracheal intubation.

The usefulness of the McGrath MAC laryngoscope in comparison with Airwayscope and Macintosh laryngoscope during routine nasotracheal intubation: a randomaized controlled trial

Background

McGrath MAC video laryngoscope offers excellent laryngosopic views and increases the success rate of orotracheal intubation in some cases. The aim of this study was to determine the usefulness of McGrath MAC for routine nasotracheal intubation by comparing McGrath MAC with Airway scope and Macintosh laryngoscope.

Methods

A total of 60 adult patients with ASA physical status class 1 or 2, aged 20–70 years were enrolled in this study. Patients were scheduled for elective oral surgery under general anesthesia with nasotracheal intubation. Exclusion criteria included lack of consent and expected difficult airway. Patients were randomly allocated to three groups: McGrath MAC (n = 20), Airway scope (n = 20), and Macintosh laryngoscope (n = 20). After induction, nasotracheal intubation was performed by six expert anesthesiologists with more than 6 years of experience.

Results

There were no significant differences in preoperative airway assessment among the three groups. Successful tracheal intubation time was 26.8 ± 5.7 (mean ± standard deviation) s for McGrath MAC, 36.4 ± 11.0 s for Airway scope, and 36.5 ± 8.9 s for Macintosh laryngoscope groups. The time for successful tracheal intubation for McGrath MAC group was significantly shorter than that for Airway scope and Macintosh laryngoscope (p < 0.01). McGrath MAC significantly improved the Cormack Lehane grade for nasotracheal intubation compared with Macintosh laryngoscope (p < 0.05).

Conclusion

McGrath MAC significantly facilitates routine nasotracheal intubation compared with Airwayscope and Macintosh laryngoscope by shortening the tracheal intubation time and improving the Cormack Lehane grade.

Trial registration

UMINCTR Registration number UMIN000023506. Registered 5 Aug 2016.

Possible association between successful intubation via the right nostril and anatomical variations of the nasopharynx during nasotracheal intubation: a multiplanar imaging study

PURPOSE

Most reported cases of nasopharyngeal laceration following impingement during nasotracheal intubation involved tube insertion via the right nostril. We postulated that recesses on the posterior wall of the nasopharynx might be associated with tube impingement. Using multiplanar imaging and clinical statistics, we evaluated whether anatomical variations in the recesses are related to successful intubation via the right nostril.

METHODS

Using multiplanar computed tomography (CT) images of 97 patients, we investigated the locations of recesses relative to the mid-sagittal plane, nasal floor plane and posterior end of the nasal septum, and their shapes. Incidents of impingement of the tube during nasotracheal intubation and the shapes of the fossa of Rosenmüller on CT images were retrospectively evaluated in 170 patients.

RESULTS

Eustachian tube orifices were located approximately 10 mm laterally from the sagittal plane, and approximately 10 mm above the nasal floor plane. The fossa of Rosenmüller was vertically elongated and located 7 mm laterally from the mid-sagittal plane. Pharyngeal bursae were found in 15 % of the subjects. Patients with failed insertion via the right nostril due to impingement frequently had a wide opening of the fossa of Rosenmüller.

CONCLUSIONS

Successful intubation via the right nostril is related to the anatomy of structures on the posterior nasopharyngeal wall, particularly recesses located close to the path of nasotracheal tube insertion. Nasopharyngeal anatomical variations should be considered when one notices any resistance to advancement of the tube into the nasopharynx during nasotracheal intubation.