Madam,
Nasotracheal intubation, first described by Kuhn[1] in 1902, popularized by Magill[2] in 1920s, finds its place in various head and neck surgeries. It offers the benefit of more surgical manoeuver ability in such surgeries. It's use is also beset with a number of complications. such as bleeding through the Kisselbach's plexus[3] lacerations, turbinate avulsion, nasal polyp or tumor avulsion, bacteremia, and retropharyngeal mucosa dissection/laceration. Complications may also lead to death due to excessive hemorrhage or choking due to an avulsed turbinate.
Nasotracheal intubation remains one of the established techniques of securing the airway. Careful assessment and preparation of the patient before the procedure are important. Various complications such as epistaxis, polypectomy, adenoidectomy, and turbinectomy have all been described. The incidence of these complications is variable. Tintinalli and Claffey, with nasotracheal intubations, demonstrated a hemorrhage rate of 17%.[4] Nasal anatomy aberrations such as septal deviations and septal spurs are common. Studies have shown that eliciting proper history and evaluation of nasal patency clinically, though recommended, might be misleading.[5] Septal spurs might provide obstacle while intubating [Figure 1] and can lead to complications like bleeding. The use of anterior rhinoscopy has not shown to be of much benefit.[6] Flexible fiberoptic bronchoscopy is advised to reveal anatomical aberrations. However, in a resource-limited setting, a video rhinolaryngoscope (VRL) can prove to be handy. The presence of a septal spur can be picked up easily. A VRL is similar to a fiberoptic bronchoscope but with limited length (30 cm), outer diameter 3.7 mm and angle of view 85°. It is portable and relatively easy to use. The disadvantage of this unit is the absence of suction port. In our case, we used it only for a diagnostic purpose.
Figure 1.
Left-sided spur on video rhinolaryngoscope image
Hence, we recommend that the use of VRL in a resource-limited setting in patients undergoing nasal intubation. Carrying out nasotracheal intubation, relying just on preoperative assessment like nasal patency determination by air flow methods, that have so far been used, can be catastrophic. Heretic, as it may sound, a preoperative evaluation with VRL under sedation/general anesthesia might prove useful, as was seen in our patient. Regular nasal assessment using VRL under sedation has the potential to decrease the complication rate, thus increasing the patient safety.
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References
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