Nasotracheal Intubation

Updated: Dec 21, 2015
  • Author: Marina Shindell, DO; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Nasotracheal intubation may be performed in patients undergoing maxillofacial surgery or dental procedures or when orotracheal intubation is not feasible (eg, patients with limited mouth opening). [1] Nasotracheal intubation (see the video below) used to be the preferred route for prolonged intubation in critical care units, but nasal damage, sinusitis, [2] and local abscesses have limited its use. Because of the necessity of longer and narrower tubes for the nasal route, pulmonary toilet is more difficult and airway resistance is greater. The nasal route in the spontaneously ventilating patient was once considered a technique of choice for emergency operations, but orotracheal intubation under direct vision following the rapid sequence induction of anesthesia is now the technique of choice.

Nasotracheal intubation (blind and unblinded). Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.


Most commonly, this technique is employed in the operating room for dental procedures and intraoral (eg, mandibular reconstructive procedures or mandibular osteotomies) and oropharyngeal surgeries. Some authors advocate using nasotracheal intubation for minor otolaryngologic and maxillofacial surgeries, as they believe the technique is underused in the current practice. [3]

Other indications include securing the airway in patients with questionable cervical spine stability or severe degenerative cervical spine disease (using awake fiberoptic intubation technique), patients with intraoral mass lesions or structural abnormalities, and patients with limited mouth opening (eg, trismus).



Absolute contraindications

Absolute contraindications to nasotracheal intubation include the following:

  • Suspected epiglottitis
  • Midface instability
  • Coagulopathy
  • Suspected basilar skull fractures
  • Apnea or impending respiratory arrest (Any patient with advanced upper airway obstruction, who is apneic or having difficulties maintaining his or her airway, should not be subjected to any form of awake intubation.)

Relative contraindications

Relative contraindications to nasotracheal intubation include the following:

  • Large nasal polyps
  • Suspected nasal foreign bodies
  • Recent nasal surgery
  • Upper neck hematoma or infection
  • History of frequent episodes of epistaxis
  • Prosthetic heart valves (increased risk of bacteremia during the insertion)


General anesthesia: If no difficulties are suspected in securing the airway, based on the physical examination or prior history of intubation, general anesthesia and neuromuscular blockade can be induced. General anesthesia is routinely induced using rapid-acting hypnotic or induction agents (eg, propofol, etomidate, thiopental, ketamine).

Assess mask ventilation before neuromuscular blockade: After anesthesia induction, assess the ability to mask-ventilate the patient prior to giving neuromuscular blockers (except in the case of rapid sequence induction, when mask ventilation is not attempted, and succinylcholine or rocuronium is administered simultaneous to the hypnotic agent). After the neuromuscular blocker drug is administered and given time to achieve maximal effect, perform direct laryngoscopy or blind intubation.

Prepping nasal passages: Lubricants and vasoconstrictors are commonly applied to the nasal passages prior to introduction of an endotracheal tube. Various vasoconstrictors are available, such as cocaine 4% solution (not to exceed 1.5 mg/kg), oxymetazoline 0.05% nasal spray (Afrin), or phenylephrine nose drops 0.25-1% (Neo-Synephrine). The choice of vasoconstrictor is usually at the anesthetist's preference. Applying lidocaine jelly or water-soluble lubricant allows for smoother advance as well as better transfer of rotation along the endotracheal tube's length during directional manipulation.

Fiberoptic intubation: If awake, fiberoptic intubation is necessary; prepare the patient's nasal passages as described above. Additionally, in awake or sedated patients, topical anesthesia to the patient's larynx and pharynx is also required. This can be accomplished by a number of techniques, such as transoral application of a local anesthetic agent or use of superior laryngeal nerve block with 4% lidocaine (up to 3 mg/kg) administered transtracheally or sprayed down the fiberscope's lumen intermittently in advance of the scope's passage. Incomplete topical anesthesia not only causes patient discomfort, it makes the procedure much more difficult and may lead to patient morbidity. An antisialagogue drug is administered (eg, glycopyrrolate 0.2-0.3 mg IV) to improve the visualization of the field. Small amounts of sedation are advocated as well, keeping in mind that sedation is not a substitute for a well anesthetized airway. [4]



Equipment required for nasotracheal intubation include the following:

  • Endotracheal tube (Nasal Rae [see image below] or the regular endotracheal tube)
    Nasal Rae endotracheal tube. Nasal Rae endotracheal tube.
  • Lidocaine jelly or any other water-soluble lubricant
  • Magill forceps (see image below)
    Magill forceps. Magill forceps.
  • Afrin spray (oxymetazoline 0.05%)
  • Nasal trumpets
  • Syringe to inflate the cuff
  • Suction
  • Intubation equipment (eg, laryngoscope, Glide-scope, fiberoptic scope)

Commercial airway device adjuncts are available. A novel intubation system, GlideScope Video Laryngoscope (GVL, Verathon Medical Inc., Bothell, Wa) has an established role in routine and difficult orotracheal intubation not only by experienced handlers but also by novices. [5, 6] In a recent study, authors showed GVL superiority compared to direct laryngoscopy in improvement of time to successful intubation and in regard to lower incidence of moderate to severe sore throat postoperatively. [7]



For the induction of general anesthesia, the patient should be in the supine position.

If the patient is awake, fiberoptic intubation (or any other awake intubation) is pursued; often the most practical position may be sitting (on the operating room table) as it prevents the larynx from falling posteriorly as it does in the supine position.



Establish patency of the nares with a well-lubricated nasal trumpet (see images below).

Inserting nasal trumpet. Notice that insertion ang Inserting nasal trumpet. Notice that insertion angle is almost perpendicular to the face.
Nasal trumpet insertion (continued). Nasal trumpet insertion (continued).

Insert a well-lubricated tube with fully deflated cuff via a patent, lubricated naris, at a right angle to the face (see image below).

Direct laryngoscopy with Miller blade. Insert Nasa Direct laryngoscopy with Miller blade. Insert Nasal Rae endotracheal tube and advance it a little prior to putting the laryngoscope in the mouth.

Some resistance is commonly encountered, most likely due to the right arytenoid. This is usually overcome with slight counterclockwise rotation of the tube.

Once the tube is beyond the nasopharynx, introduce the laryngoscope into the oral cavity and advance the tube under direct vision (see images below).

Once the vocal cords are seen, the endotracheal tu Once the vocal cords are seen, the endotracheal tube is advanced by the laryngoscopist or an assistant.
Magill forceps directing the endotracheal tube (ab Magill forceps directing the endotracheal tube (above the cuff) for its advance through the vocal cords.

Sometimes, to avoid tearing the cuff with the forceps, Magill forceps are needed to guide the tube through the vocal cords; if this is the case, an assistant advances the tube (see image below).

The endotracheal tube is advanced using Magill for The endotracheal tube is advanced using Magill forceps by the laryngoscopist. An assistant helps advance the tube by slowly pushing it in.


Complications to nasotracheal intubation include the following:

  • Epistaxis: This is the most common complication, resulting from abrasion of the nasal mucosa when the tube is passed posteriorly. If bleeding is noticed but intubation could still be achieved, then it should be completed. An endotracheal tube in proper position allows tamponade of the bleeding and protects the airway. If repeated attempts are needed, then the tube should be withdrawn until the cuff is positioned to be inflated in order to tamponade the bleeding (usually in the postnasal space). Another option is to withdraw the tube completely and pinch the nostrils together.
  • Damage to nasal cavity (avulsion of nasal polyps, fracture of the turbinates, septal abscesses)
  • Aspiration
  • Vagal stimulation
  • Laryngospasm
  • Vocal cord damage [8]
  • Bacteremia from introduction of nasal flora to the trachea