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A New Technique to Reduce Epistaxis and Enhance
Navigability During Nasotracheal Intubation
Kwang Suk Seo, MD*
Jae-Hun Kim, MD†
Sol Mon Yang, MD†
Hyun Jeong Kim, MD*
Jae-Hyon Bahk, MD†
Kwang Won Yum, MD*
BACKGROUND: Epistaxis is the most common complication of nasotracheal intubation. We compared endotracheal tubes (ETT) obturated with an inflated esophageal
stethoscope with normal ETTs with regard to the prevention of epistaxis and
navigability, both with and without thermosoftening.
METHODS: Dental surgical patients requiring nasotracheal intubation were randomly
allocated into 1 of 4 groups (n ⫽ 50 each): Group 1, nonthermosoftened ETTs;
Group 2, nonthermosoftened ETTs obturated with an inflated esophageal stethoscope; Group 3, thermosoftened ETTs; and Group 4, thermosoftened ETTs obturated with an inflated esophageal stethoscope. Navigability of ETTs through the
nasal cavity and postintubation epistaxis were evaluated.
RESULTS: Navigability of ETTs through the nasal cavity was the worst in Group 1
(P ⫽ 0.001). Epistaxis was the most severe in Group 1, similar between Groups 2
and 3, and the least severe in Group 4 (P ⬍ 0.001).
CONCLUSION: The use of esophageal stethoscope-obturated ETTs was effective, and
comparable to thermosoftening, in preventing epistaxis associated with nasotracheal intubation. Thermosoftened, obturated ETTs were more effective than simple
thermosoftened ETTs in reducing epistaxis.
(Anesth Analg 2007;105:1420 –4)
N
asotracheal intubation may cause nasal mucosa or
concha damage (1). The most common complication
associated with nasotracheal intubation is epistaxis
(2,3). Even obstruction of an endotracheal tube (ETT)
by a torn nasal tissue has been reported (4,5).
Nasal and nasopharyngeal mucosal damage during
nasotracheal intubation seems to be caused by a rigid
tip or a sharp-edged Murphy eye of conventional
ETTs (6 – 8). Many methods have been suggested to
decrease trauma associated with nasotracheal intubation, including thermosoftening of the ETT (7,9), use of
a red rubber airway or catheter as a guide (6,10), and
obturation of the nasotracheal tube with an intraluminal balloon at the ETT tip (8,11).
Obturation of the ETT tip with an inflated esophageal stethoscope has been suggested (11), but not
tested, for reducing epistaxis. We hypothesized that
the round, obturated ETT tip would facilitates easy
passage though the nasal cavity, minimizing nasal
trauma. This study was performed to assess whether
From the *Department of Dental Anesthesiology and Dental
Research Institute, Seoul National University School of Dentistry,
and †Department of Anesthesiology, Seoul National University
Hospital, Seoul National University College of Medicine, Seoul,
Korea.
Accepted for publication July 5, 2007.
Address correspondence and reprint requests to Dr. Jae-Hyon
Bahk, Department of Anesthesiology, Seoul National University
Hospital, Seoul National University College of Medicine, 28
Yongon-dong Jongno-gu, Seoul, Korea 110-744. Address e-mail to
[email protected].
Copyright © 2007 International Anesthesia Research Society
DOI: 10.1213/01.ane.0000281156.64133.bd
1420
obturation of a conventional, Murphy-tipped ETT
with an inflated stethoscope reduces epistaxis and
enhances navigability through the nasal cavity, and to
compare the benefit (if any) of obturation with that of
thermosoftening.
METHODS
After obtaining IRB approval and written informed
consent, 200 adult patients, who were ASA physical
status I or II and ⬍65-yr-old, were enrolled. All
patients were scheduled for elective dental surgery
requiring nasotracheal intubation to optimize the surgical approach. Procedures comprised 68 orthognatic
surgeries, 7 mandible fracture fixations, 44 benign
tumor excisions, 15 surgical tooth extractions, 6 plate
removals, 30 oral cancer surgeries, 24 multiimplants
insertions, 4 abscess drainages, and 2 temporomandibular joint surgeries. Patients were excluded if they
had a documented history of difficult intubation, a
potentially difficult airway suggested by physical examination, obstructive sleep apnea, a history of nasal
surgery, nasal trauma, nasal deformity, recurrent epistaxis, or bleeding diathesis, a history of taking anticoagulant drugs, or risks for aspiration.
No preanesthetic medication was administered. After
applying routine monitoring, such as an electrocardiogram, pulse oximetry, capnometry, and noninvasive
arterial blood pressure, patients were placed in the
supine position with the head on a 8-cm-high pillow.
After anesthesia induction using propofol 1.5 mg/kg
IV after lidocaine 30 mg IV, and neuromuscular blockade with vecuronium 0.1 mg/kg IV, the lungs were
Vol. 105, No. 5, November 2007
Figure 1. Esophageal stethoscope and endotracheal tube combination. The proximal end of a
pediatric esophageal stethoscope was connected
to a syringe via 3-way stopcock with its tip
protruding about 0.5 cm out of the distal end of
an endotracheal tube. Injecting about 2 mL of air
and locking the 3-way stopcock keeps the distal
tip of the balloon inflated. Inset: Enlarged view
of the endotracheal tube tip.
ventilated with 7– 8 vol % sevoflurane in 100% O2 via
a facial mask.
Murphy-tipped, preformed ETTs (RAETM Nasal,
Mallinckrodt Medical, Athlone, Ireland) were used for
nasotracheal intubation. A 7.0-mm internal diameter
ETT was used for men and a 6.5-mm internal diameter
ETT for women. Patients were randomized to one of
following four groups using sealed envelopes opened
after induction of anesthesia.
Group 1: ETTs were put into a bottle of sterilized
saline at room temperature (24°C ⫾ 1°C).
Group 2: ETTs obturated with an inflated esophageal stethoscope were put into a bottle of sterilized saline at room temperature (24°C ⫾ 1°C).
Group 3: ETTs were put into a bottle of sterilized
saline warmed to 40°C ⫾ 1°C.
Group 4: ETTs obturated with an inflated esophageal stethoscope were put into a bottle of sterilized saline warmed to 40°C ⫾ 1°C.
Vol. 105, No. 5, November 2007
In Groups 2 and 4, the proximal end of a 12F
pediatric esophageal stethoscope (Premier series™, De
Royal Industries, Inc., Powell, TN) was connected to a
10-mL syringe via a 3-way stopcock. Air inside the
distal balloon of a stethoscope was completely aspirated using the syringe before insertion into the ETT.
After lubrication with water-soluble jelly, the stethoscope was advanced into the ETT and positioned with
its tip protruding about 0.5 cm out of the distal end of
the ETT. Injecting about 2 mL of air and locking the
3-way stopcock kept the distal tip of the balloon
inflated (11) (Fig. 1). All ETTs, with or without an
inflated esophageal stethoscope, were lubricated with
water-soluble jelly immediately before intubation.
During the preanesthetic interview, patients were
questioned as to which nostril was easier to breathe
through. The selected nostril was chosen for intubation.
If breathing conditions were equal bilaterally, then the
left nostril was chosen because of surgeons’ preference.
© 2007 International Anesthesia Research Society
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Table 1. Patient and Intubation Characteristics
Patient characteristics
Group 1
Group 2
Group 3
Group 4
Age (yr)
Weight (kg)
Height (cm)
Sex (M:F)
ASA grade (I/II)
Intubation characteristics
Nostril (right/left)
Attempts (1/2/3)
Navigability (smooth/impinged)
39 ⫾ 17
60 ⫾ 11
165 ⫾ 9
28:22
36/14
36 ⫾ 17
62 ⫾ 12
168 ⫾ 8
29:21
42/8
38 ⫾ 16
66 ⫾ 15
167 ⫾ 9
27:23
40/10
37 ⫾ 15
62 ⫾ 10
167 ⫾ 7
27:23
42/8
22/28
45/5/0
27/23*
18/32
46/3/1
35/15
23/27
47/1/2
39/11
19/31
44/6/0
43/7
Values are mean ⫾ SD or number of patients.
N ⫽ 50 in each group.
Group 1, nonthermosoftened endotracheal tubes; Group 2, nonthermosoftened endotracheal tubes that were obturated with an inflated esophageal stethoscope; Group 3, thermosoftened
endotracheal tubes; and Group 4, thermosoftened endotracheal tubes that were obturated with an inflated esophageal stethoscope.
* P ⫽ 0.001 versus the other three groups.
Table 2. Severity of Epistaxis and Incidence of Nasal
Complications After Nasotracheal Intubation
Group Group Group Group
1*
2
3
4†
Epistaxis
None
Slight
Moderate
Severe
Nasal complications
Nasal pain
Persistent bleeding
Difficult nasal
breathing
Blood crust or
mucosal tearing
7
22
19
2
16
21
12
1
18
20
12
30
14
5
1
15
7
0
12
5
0
10
5
1
3‡
4
0
13§
6
4
3
Values are number of patients.
N ⫽ 50 in each group.
Group 1, nonthermosoftened endotracheal tubes; Group 2, nonthermosoftened endotracheal
tubes that were obturated with an inflated esophageal stethoscope; Group 3, thermosoftened
endotracheal tubes; and Group 4, thermosoftened endotracheal tubes that were obturated
with an inflated esophageal stethoscope.
The severity of epistaxis was graded according to the distance that blood traveled up the suction
catheter and tubing: none ⫽ no blood aspirated; slight ⫽ blood aspirated by ⬍50 cm;
moderated ⫽ blood aspirated by 50 –300 cm; and severe ⫽ blood aspirated by ⬎300 cm.
* P ⬍ 0.001 and † P ⬍ 0.001 versus the other three groups with regard to severity of
epistaxis; ‡ P ⫽ 0.003 versus the other three groups with regard to incidence of nasal pain;
§ P ⫽ 0.002 versus the other three groups with regard to incidence of blood crust or mucosal
tearing.
After induction of anesthesia, the ETT, with or
without obturation or thermosoftening, was inserted
through the selected nostril. If some resistance was
felt, the tube was withdrawn and the following manipulations were applied in sequence (9): (a) counterclockwise rotation with gentle cephalad tilting of the
tube, (b) reinsertion into the other nostril, and (c)
reinsertion into the other nostril with counterclockwise rotation and gentle cephalad tilting of the tube.
Two anesthesiologists (HJK and KSS) performed all
intubations. In Groups 2 and 4, after advancing the
ETT into the oropharynx, all air inside the esophageal
stethoscope was aspirated, and the stethoscope was
removed from the ETT. All intubations were completed using a fiberoptic bronchoscope (LF-2, Olympus, Tokyo, Japan).
The anesthesiologists who performed the intubations recorded the number of attempts to insert the
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Epistaxis and Navigability During Nasotracheal Intubation
ETT into the nasal cavity and estimated the degree of
navigability through the nasal passage, defined as
smooth or impinged (any subjective feeling of obstruction while passing an ETT) (9). Another anesthesiologist who was blinded to the groups estimated the
severity of epistaxis 5 min after the intubation. Epistaxis was measured by aspirating the pharynx using
a 14F, 50-cm-long suction catheter connected to a
2.5-m-long suction tubing at a pressure of 100 mm Hg.
Epistaxis severity was graded according to the distance that blood traveled up the suction tubing (9,12):
none ⫽ no blood aspirated; slight ⫽ blood aspirated
by ⬍50 cm; moderate ⫽ blood aspirated by 50 –300
cm; and severe ⫽ blood aspirated by ⬎300 cm. Before
discharge from the postanesthesia care unit, all patients were checked for difficulty with nasal breathing,
persistent nasal bleeding, and postoperative nasal
pain. The anesthesiologist who had checked epistaxis
assessed the nasal damage, such as blood crust and
mucosal tearing, on the first postoperative day.
Based on the results of a pilot study (n ⫽ 30), a
power analysis indicated that 50 patients per group
would be sufficient to detect the difference in the
severity of epistaxis between the nonthermosoftened
groups with or without obturation with a power
⬎80% at the level of significance of 0.05. Data are
expressed as mean ⫾ sd or number of patients.
Patients’ characteristics were compared by ANOVA or
␹2 test as appropriate. The Kruskal–Wallis test was
used to compare the severity of epistaxis and the
multiple comparisons among groups were analyzed
by the Wilcoxon’s ranked sum test. Intubation characteristics and postprocedure complications were compared using ␹2 test or Fisher’s exact test. The SPSS
software (version 12.0; SPSS Inc., Chicago, IL) was
used. P ⬍ 0.05 was regarded as significant.
RESULTS
There were no statistical differences among groups
regarding age, sex, height, weight, ASA physical status,
types of surgery, choice of nostril, and number of attempts to intubate. There were no intubation failures.
ANESTHESIA & ANALGESIA
Navigability of the ETT through the nasal cavity
was the worst in Group 1 (P ⫽ 0.001, Table 1). The
incidence of nasal bleeding was 86% in Group 1, 68%
in Group 2, 64% in Group 3, and 40% in Group 4.
Based on the multiple comparisons, Group 1 had the
most severe epistaxis, and Group 4 had the least
severe epistaxis (P ⬍ 0.001, Table 2).
Postoperative nasal pain was less frequent in Group
4 than in all the other groups (P ⫽ 0.003). Mucosal
injury was more frequent in Group 1 than in all the
other groups (P ⫽ 0.002, Table 2). There were no
significant differences among groups in the incidences
of difficult nasal breathing or persistent bleeding.
Even in cases of severe bleeding in Groups 2 and 4,
fiberoptic bronchoscope-guided intubation provided
clear views, succeeding in advancing the fiberoscope
immediately.
DISCUSSION
The esophageal stethoscope-obturated ETT was comparable to the thermosoftened ETT in regard to the
incidence and severity of epistaxis. The obturated, thermosoftened ETT was more effective in reducing epistaxis than the thermosoftened ETT. Balloon-obturation
or thermosoftening of ETT tips were effective in enhancing navigability through the nasal cavity.
Several methods have been used to reduce epistaxis
during nasotracheal intubation. Topical vasoconstrictors, such as epinephrine, phenylephrine, xylometazoline, oxymetazoline, and cocaine, can reduce epistaxis
(13,14). However, these have been associated with
life-threatening complications such as arrhythmia,
myocardial infarction, and cardiac arrest (15–17).
Therefore, the use of topical vasoconstrictors should
be restricted, especially in patients with coronary
artery disease.
Thermosoftening is a well known and effective
technique for reducing epistaxis (7,9), but it is not
without risks. Overheating can distort and obstruct
the ETT, particularly at the tube’s weakest point
where the inflation lumen opens into the cuff (18), so
that the temperature of saline must be controlled.
Therefore, there is a need for a risk-free, economical
nasotracheal intubation.
Use of a red rubber catheter or airway (6,10) or
obturation of the ETT tip with an intraluminal balloon
(8) can also reduce epistaxis. After passing through the
nasal cavity, the disposable catheter or airway should
be removed through the oral cavity with forceps and
discarded. A commercial intraluminal balloon has
been developed (8), but is not widely available.
One of our authors (J-HB) suggested in a correspondence that an esophageal stethoscope and ETT combination could reduce the trauma of nasotracheal
intubation (11). Indeed, the esophageal stethoscope
used for obturating the ETT could then be recycled as
a stethoscope for the same patient.
Although a Murphy-tipped ETT is more traumatic
than a Magill-tipped ETT (9), only a Murphy-tipped
Vol. 105, No. 5, November 2007
ETT was used in this study because it seems to be used
more frequently in clinical anesthesia. Prior studies
have shown that a rounder or softer ETT tip is less
traumatic for nasotracheal intubation (8,9,12). In this
study, the main reason for the effectiveness of the
obturated ETT seems to be that, while advancing
through the nasal cavity, the advancing surface is a
round balloon end. Simultaneous sealing of the Murphy eye may provide additional protection against
nasal trauma.
There are some limitations to this study. First,
consistent with our routine practice, we did not use a
topical vasoconstrictor. Second, as previously mentioned, Magill-tipped ETTs were not studied. A further study about obturation of Magill-tipped ETTs
may be needed. Lastly, navigability and postoperative
nasal pain could not be quantitatively assessed. There
is no practical way to objectively evaluate the navigability through the nasal cavity. For evaluation of the
nasal pain, there were confounding factors, such as
type of surgery and postoperative analgesia. However, since types of surgeries were evenly distributed
among the four groups, we believe that the interpretation of the results would not change.
During nasotracheal intubation, obturation of the ETT
with an inflated esophageal stethoscope was as effective
as thermosoftening in the prevention of nasal trauma
and the navigability through the nasal cavity. The best
combination included both thermosoftening and obturation of the ETT to minimize trauma and epistaxis.
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ANESTHESIA & ANALGESIA