Background
Nasotracheal intubation may be performed in patients undergoing maxillofacial surgery or dental procedures or when orotracheal intubation is not feasible (eg, in patients with limited mouth opening). [1, 2]
Nasotracheal intubation used to be the preferred route for prolonged intubation in critical care units, but nasal damage, sinusitis, [3] and local abscesses have limited its use. In January 2019, guidelines on intubation and extubation in the intensive care unit (ICU) were published by the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French-Speaking Intensive Care Society (SRLF). [4]
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.
Indications
Most commonly, this technique is employed in the operating room for dental procedures and intraoral (eg, mandibular reconstructive procedures or mandibular osteotomies) and oropharyngeal operations. Some authors advocate using nasotracheal intubation for minor otolaryngologic and maxillofacial surgical procedures, maintaining that the technique is underused in current practice. [5]
Other indications include securing the airway in patients with questionable cervical spine stability or severe degenerative cervical spine disease (using the awake fiberoptic intubation technique), patients with intraoral mass lesions or structural abnormalities, and patients with limited mouth opening (eg, trismus).
Contraindications
Absolute contraindications for nasotracheal intubation include the following:
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Suspected epiglottitis
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Midface instability
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Coagulopathy
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Suspected basilar skull fractures
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Apnea or impending respiratory arrest - Any patient with advanced upper-airway obstruction who is apneic or is having difficulties maintaining his or her airway should not be subjected to any form of awake intubation
Relative contraindications for nasotracheal intubation include the following:
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Large nasal polyps
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Suspected nasal foreign bodies
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Recent nasal surgery
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Upper-neck hematoma or infection
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History of frequent episodes of epistaxis
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Prosthetic heart valves (increased risk of bacteremia with tube insertion)
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Nasal RAE (Ring-Adair-Elwyn) endotracheal tube.
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Magill forceps.
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Inserting nasal trumpet. Note that insertion angle is almost perpendicular to face.
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Nasal trumpet insertion (continued).
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Direct laryngoscopy with Miller blade. Insert nasal RAE endotracheal tube, and advance it a little before putting laryngoscope in mouth.
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Once vocal cords are seen, endotracheal tube is advanced by laryngoscopist or assistant.
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Endotracheal tube is advanced with Magill forceps by laryngoscopist. Assistant helps advance tube by slowly pushing it in.
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Magill forceps directing endotracheal tube (above cuff) for its advance through vocal cords.
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Nasotracheal intubation (blind and unblinded). Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
