Sir,
For nasotracheal intubation (NTI), armored tubes allow head and neck manipulation without risk of kinking of the tube during surgery. Due to its inherent flexibility, intubation with an armored tube has its own sets of difficulties.[1] These tubes tend to move along the posterior pharyngeal wall toward esophagus rather than toward laryngeal inlet or it may pass through vocal cords but may not be negotiated into subglottic region. Magill forceps is almost always required to navigate the tip of tube into vocal cords which may injure tube cuff or the oropharyngeal mucosa.
To overcome these issues, we are routinely performing NTI with aid of malleable stylet. After introducing stylet, the tube-stylet assembly is molded to have a gentle bend in middle of the tube. Care is taken that tip of stylet remains within 2–3 mm of the end of the tube. Tube-stylet assembly is advanced through more patent nostril with gentle pressure till nasopharynx. Although Magill forceps may be required to direct tip toward glottis but manipulation of tip becomes easier by holding the tube proximal to cuff decreasing the likelihood of injury to cuff and surrounding structures. It is especially a valuable technique in subjects with Cormack-Lehane Grade III or IV in which directing the tube toward larynx would be difficult.
Several mechanical devices have been described to aid NTI including suction catheter, nasogastric tubes, and gum elastic bougie.[2,3,4] Although stylet had also been reported to facilitate blind NTI, it is not used routinely because of anticipated risk of trauma, bleeding, creation of false passage, and injury to adenoid tissue.[5] However, these complications can occur with the armored tube without stylet also if undue force is applied. The use of stylet is not associated with increased incidences of trauma or bleeding in our routine practice. Therefore, use of stylet in armored tracheal tube can be considered as an effective tool for NTI.
Yours sincerely
Pooja Bihani,
Senior Resident, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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