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Table of Contents
Year : 2022  |  Volume : 11  |  Issue : 5  |  Page : 30-33

Retrograde nasal intubation for an anticipated difficult intubation

Department of Anaesthesiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Submission31-Dec-2020
Date of Acceptance05-Jan-2022
Date of Web Publication08-Jun-2022

Correspondence Address:
Natham Hemanth
Associate Professor, Department of Anaesthesiology, Sri Venkateswara Institute of Medical Sciences, Tirupati 517 507, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcsr.jcsr_109_20

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A 58-year-old female patient with recurrence of carcinoma in the angle of the mouth on the left side was posted for composite resection and Pectoralis major myocutaneous flap reconstruction. The patient had carcinoma left buccal mucosa 1 year back and had undergone left partial mandiblectomy and radiotherapy. On airway examination (MPG) could not be assessed; on mouth opening one-and-half finger was admitted. There was a 4 cm × 4 cm ulceroproliferative growth in the left angle of the mouth extending to lower lip, which was bleeding on touch. After shifting to the operating theatre, venous access was secured with a with a wide-bore cannula. Standard monitoring was connected and preoxygenation was done. Under strict aseptic precaution under local anaesthesia, trachea located with Touhy's needle. Epidural catheter passed through the needle into the larynx and taken out through the oral cavity and Ryle's tube, which the patient already had for feeds, was pulled and taken out of the oral cavity. Catheter tip was tied to it and pulled out through the nostril and passed through murphy's eye of 6.5 mm (ID ETT) and lower end pulled, thereby pulling ETT into the trachea, cuff was inflated and tube fixed at 25 cm. General anaesthesia was administered. Thorough airway assessment, preparat ion and counselling of patient help in reducing airway-related morbidity and mortality.

Keywords: Difficult airway, limited mouth opening, retrograde nasal intubation

How to cite this article:
Linnet S, Hemanth N, Samantaray A, Rao M H. Retrograde nasal intubation for an anticipated difficult intubation. J Clin Sci Res 2022;11, Suppl S1:30-3

How to cite this URL:
Linnet S, Hemanth N, Samantaray A, Rao M H. Retrograde nasal intubation for an anticipated difficult intubation. J Clin Sci Res [serial online] 2022 [cited 2022 Oct 6];11, Suppl S1:30-3. Available from: https://www.jcsr.co.in/text.asp?2022/11/5/30/355069

  Introduction Top

Patients with limited mouth opening (LMO) conditions increase the difficulty in securing the airway.[1],[2] Maxillofacial surgical patients present with specific challenges for the surgeon and anaesthetist. Blind nasal intubation remains an importa nt auxiliary subsidising airway in such patients when fibre-optic bronchoscope is not available.[3],[4],[5] The key in these situations is to perform an elective short-term tracheostomy before the operation which carries a high incidence of complications. Nasal route intubation is more favourable as these patients require surgical procedur e s either intraoral, extraor al or both.[6]

Retrograd e intubation is an elective or emergency technique for securing difficult airway, alone or in conjunction with other techniques.[7] It is the safe and easy method of intubation, especially in patients with airway trauma or in the presence of oropharyngeal bleeding, obscuring the field of fiberscope.[8]

  Case Report Top

A 58-year-old female patient weighing 58 Kg came with recurrence of carcinoma in the left angle of the mouth posted for composite resection and Pectoralis major myocutaneous flap reconstruction. The patient had carcinoma left buccal mucosa 1 year back and had undergone left partial mandiblectomy and radiotherapy.

The patient was unable to take solid diet and was on liquid and semiliquid diet through Ryle's tube. The patient' s mouth opening was admitting one and a half finger. Mallampatti grade could not be assessed. A 4 cm × 4 cm ulceroproliferative growth is seen in the left angle of the mouth extending to lower lip, which bleeds on touch [Figure 1]. Airway examination was normal; both nostrils were patent; mentohyoid and thyromental distances were normal. The patient had no complaint of dyspnoea or change of voice or snoring during sleep. We explained to patient's relatives that the technique may fail and consent for tracheostomy was taken. We planned for awake nasal intubation. We did the following preparations. Difficult airway kit and tracheostomy tray was kept ready. Two drops of xylometazolin were applied in each nostril. Lignocaine jelly applied inside nasal cavities and lignocaine infiltration given over the area for cricothyroid membrane puncture. A well lubricated nasopharyngeal airway inserted in the left nostril of patient.
Figure 1: Preoperative clinical photograph of the patient with Ryle's tube insitu in left nostrils. Patient had 4cm x 4cm ulceroproliferative growth in left angle of mouth. This picture shows patient had pressure bandage to stop bleeding

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oxygen saturation measured with pulse oximetry (SpO2), end-tidal carbon dioxide (EtCO2), electrocardiography and non-invasive blood pressure were monitored.

The patient was positioned in full neck extension. A small pillow underneath the shoulder and head ring was kept. Intravenous injection ondansetron 8 mg, injection glycopyrrolate 0.2 mg, injection fentanyl 100 μg and injection midazolam 1 mg were administered and tried for nasal intubation with 6.5 mm endotracheal tube. EtCO2 and brain circuit were attached for the early detection of endotracheal intubation. We gave titrated dose of injection propofol.

Thorough oral and nasal suction was done. Under strict aseptic preparation under local anaesthesia, cricothyroid membrane was punctured with 18G Touhy's needle and 2 ml of 2% lignocaine was instilled into the trachea and epidural catheter no. 18 was inserted [Figure 2]. The catheter was retrieved through the oral cavity using Magill forceps [Figure 3]. Next, we utilised Ryles tube which the patient already had for feeds in the right nostril and brought it forward into the oral cavity using Magills forceps and tied it up with epidural catheter [Figure 4]. Then, we pulled Ryle's tube from the nose up to sufficient length till epidural catheter was retrieved from the right nostril. We threaded endotracheal tube number 6.5 mm over the catheter and inserted beyond vocal cords by pulling the other end of the catheter. Bilateral air entry was checked, and position of the tube was confirme d with EtCO2. Cuff inflated and tube fixed at 25 cm [Figure 5]. Anaesthetic induction was done with intravenous propofol 100 mg and vecuronium 6 mg and maintained with oxygen, air, isoflurane and injection vecuronium.
Figure 2: Clinical photograph showing cricothyroidotomy being done with 18G Touhy's needle

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Figure 3: Clinical photograph showing the epidural catheter being passed through Touhy's needle and received orally

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Figure 4: Clinical photograph showing the epidural catheter which was received orally being tied to the Ryle's tube which was retracted orally

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Figure 5: Clinical photograph showing endotracheal tube in right nostril and a new Ryle's tube placed in left nostril

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  Discussion Top

Three options are available for intubation in cases with LMO. These include blind nasal intubation, retrograde intubation and fibreoptic laryngoscopy. Blind nasal intubation may fail and may result in traum a. Fiber optic laryngoscope may obscure the visualisation of the larynx because while passing the scope, it may touch the ulceroproliferative growth in the mouth and it may bleed and pose difficulty in intubating the patients.[9] Retrograd e catheter intubation is well-known alternative method for securing the airway in difficult airway algorithm.

Applied anatomy of the cricothyroid membran e and retrograde approach has several advantag e s including the absenc e of bleeding as there are no vessels and fewer chances of subglottic oedema and stenosis. Insertion of nasopha ryngeal airway is very important. The main site of nasal narrowing is the nasal valve. To overcome this obstruction, we introduce d a lubricated nasopharyngeal airway.

A number of technical and procedural problems may arise using retrograde intubation method. According to availability of retrograde intubation set, venous catheter, epidural catheter or Seldinger's wire can be used for retrograde intubation technique. Due to unavailability of retrograde intubation set, we used epidural catheter with 18G needle which is available everywhere. The tendency of a soft epidural catheter is to exit orally, and with our technique, it can be made to come through the nose. An epidural catheter was selected to minimise trauma. An epidural catheter can be kept in situ after the airway is secured and because of its flexibility the tracheal tube can be easily advanced beyond the catheter insertion site without trauma.

In a prospective randomised study[10] authors had used J tipped vascular guidewire and modified tracheal tube guide with side-eye for retrograde intubation to avoid laryngeal trauma. In our study, we did not find any difficulty in retrieving epidural catheter retrogradely. Another study,[11] reported that pharyngeal loop can be utilized for successful retrograd e intubation. A suction catheter with negative pressure to retrieve the tip of coiled epidural catheter blindly has also been used.[12] The retrograde intubation technique has been modified by using nasopharyngeal airway as a guide to J type guide wire to come through the nose.[13]

In our patient, we retrieved catheter from the mouth without any difficulty and it was tied to Ryle's tube and pulled through nostril by pulling the other end of Ryle's tube Literature reported that death from loss of airway still occurs in patients with difficulty in airway. In the absence of fibreoptic device, retrograde intubation technique is simple, non-traumatic and does not add any complication. A gliding knot of catheter has been fixed around the side hole of tracheal tube to pull and guide the tracheal tube down the larynx and trachea.[9] This technique is fast, relatively non traumatic, easy to perform and eliminates cause of failure.

In our case we were successful in sliding endotracheal tube over epidural cathete r without trauma. We had used Ryle's tube to assist passag e of retrogr a d e cathete r for successful retrograde intubation. This technique can be utilised as a safe and cost-effective alternative in centres which are unequipped with fibreoptic laryngoscope.

Retrograde nasotrachandeal intubation is a convenient, effective and useful technique for airway control in patients with LMO and with only a small risk potential. Thorough airway assessment, prepara tion and counselling of the patient help in reducing airway-related morbidity and mortality.

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Conflicts of interest

The authors are faculty members/Postgraduate students/ residents of Sri Venkateswara Institute of Medical Sciences, Tirupati, of which Journal of Clinical and Scientific Research is the official Publication. The article was subject to the journal's standard procedures, with peer review handled independently of these faculty and their research groups.

  References Top

American Society of Anesthesiologists Task Force on Management of the difficult airway. Practice Guidelines for Management of the difficult airway; an updated report by the American Society of Anesthesiologists Task Force on management of the difficult airway. Anesthesiology 2003;98:1269-77.  Back to cited text no. 1
Lehman H, Fleissig Y, Abid-el-raziq D, Nitzan DW. Limited mouth opening of unknown cause cured by diagnostic coronoidectomy: A new clinical entity? Br J Oral Maxillofac Surg 2015;53:230-4.  Back to cited text no. 2
Davies JA. Letter: Blind nasal intubation. Br J Anaesth 1975;47:1339-40.  Back to cited text no. 3
Jackson PM, Richard HH, Holmgreen WC. Awake blind nasoendotracheal intubation: A comprehensive review. J Oral Maxillofac Surg 1994;52:1303-11.  Back to cited text no. 4
Gill M, Madden M, Green SM. Retrograde endotracheal intubation: An investigation of indications, complications and patient outcomes. Am J Emerg Med 2005;23:123-6.  Back to cited text no. 5
Vadepally AK, Sinha BR, Subramanya AV, Agarwal A. Quest for an ideal route of intubation for oral and maxillofacial surgical manoeuvres. J Maxillofac Oral Surg 2016;15:207-16.  Back to cited text no. 6
Weksler N, Klein M, Weksler D, Sidelnick C, Chorni I, Rozentsveig V, et al. Retrograde tracheal intubation: Beyond fibreoptic endotracheal intubation. Acta Anaesthesiol Scand 2004;48:412-6.  Back to cited text no. 7
Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology 1991;75:1087-110.  Back to cited text no. 8
Abou-Madi MN, Trop D. Pulling versus guiding: A modification of retrograde guided intubation. Can J Anaesth 1989;36:336-9.  Back to cited text no. 9
Jain G, Singh DK, Yadav G, Gupta SK, Tharwani S. A modification in the tube guide to facilitate retrograde intubation: A prospective, randomised trial. Indian J Anaesth 2011;55:499-503.  Back to cited text no. 10
[PUBMED]  [Full text]  
Arya VK, Dutta A, Chari P, Sharma RK. Difficult retrograde endotracheal intubation: The utility of a pharyngeal loop. Anesth Analg 2002;94:470-3.  Back to cited text no. 11
Bhattacharya P, Biswas BK, Baniwal S. Retrieval of a retrograde catheter using suction, in patients who cannot open their mouths. Br J Anaesth 2004;92:888-901.  Back to cited text no. 12
Kamath S, Raju M, Gupta R, Kamat S. Modified technique of retrograde intubation in TMJ ankylosis. Indian J Anaesth 2008;52:196-8.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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