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      Comment on “changing nasal endotracheal tube to opposite nostril in a patient with no mouth opening under general anesthesia, after initial awake fiberoptic intubation


      Saudi Journal of Anaesthesia

      Wolters Kluwer - Medknow

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          To the Editor, We read with interest the article on “changing nasal endotracheal tube to opposite nostril in a patient with no mouth opening under general anesthesia, after initial awake fiberoptic intubation” by Barua, et al.[1] We wish to congratulate the authors for the successful management of an intraoperative problem requiring a change of nasal endotracheal tube from one nostril to the other nostril. Although the authors managed to change the endotracheal tube (ETT) successfully, we have few concerns over the management and the message being conveyed by this article. This case is an adult patient with carcinoma buccal mucosa involving the maxilla and part of the mandible and requiring wide excision of buccal mucosa, maxillectomy and segmental mandibulectomy, and most probably a reconstructive flap (which is not mentioned by authors). The same side of the nostril should not be used for nasal intubation if the plan of surgery involves a maxillectomy. So, it was the incorrect preoperative planning for airway management. This patient had nil mouth opening preoperatively. As per the surgical plan, with segmental mandibulectomy, maxillectomy, buccal mucosa wide excision, and reconstructive flap these patients mostly warrant an elective tracheostomy intraoperatively for postoperative airway patency. So, if the surgeons were unhappy with the ETT in their field, they could have easily done an early tracheostomy rather than changing the ETT from one nostril to the other. The authors passed an adult fiberoptic scope from the other nostril and then by the side of the ETT to enter the trachea. They succeeded but this can lead to a theoretical trauma to the vocal cord or membranous granuloma of the vocal cord[2] and/or prolonged hoarseness in postoperative period. In our view a proper preoperative planning of airway is required to avoid such unwanted intraoperative interventions. An airway plan should be discussed with surgeons at the time of the surgical safety checklist. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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          Granulomas of the membranous vocal fold after intubation and other airway instrumentation

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            Changing nasal endotracheal tube to opposite nostril in a patient with no mouth opening under general anesthesia, after initial awake fiberoptic intubation

            Sir, A 51-year-old male patient, with carcinoma left buccal mucosa, was posted for wide local excision along with maxillectomy and segmental mandibulectomy. On examination, there was no mouth opening. Neck movements were inadequate. However, both nostrils were equally patent. Awake fiberoptic nasal intubation was planned for securing the airway. After performing trans-tracheal block and applying lidocaine 2% jelly nasally, a fiberoptic bronchoscope (FOB) was inserted through the right nostril. A 7-mm ID cuffed nasal endotracheal tube (ETT), preloaded on the scope, was railroaded over the scope after entry to trachea and fixed after appearance of end-tidal carbon dioxide (EtCO2) waveform. Anasthesia was induced and muscle relaxant was administered. However, later at surgeon's request for better access to surgical field before the beginning of surgery, the ETT was required to be changed to the left nostril. This change of the ETT from the right to the left nostril was difficult as the already restricted mouth opening of the paralyzed patient could lead to an aggravated difficult intubation scenario. Hence, to change the ETT to the other side, a separate 7-mm ID cuffed nasal tube was loaded on the FOB and introduced into the left nostril. While the scope was advanced between the vocal cords by the side of the in-situ ETT in the right side, manual bag ventilation was continued with 100% oxygen. Cuff of the first ETT was deflated and the tracheal entry of FOB was confirmed under vision, following which the first ETT was removed. The preloaded second ETT was advanced over the scope into trachea and its position was confirmed with EtCO2 [Figure 1]. Maintenance of anesthesia was continued as planned till the end of surgery. Figure 1 (a) FOB being done through left nostril after awake intubation through right nostril. (b) ETT changed to left nostril In situations where the nasal tube needs to be changed to the other nostril in an already paralyzed patient with known difficult intubation, fiberoptic intubation through the other nostril while ventilating the patient with the in-situ ETT was the safest method which maintained the ventilation, oxygenation and depth of anesthesia. However, the requisites for this approach are that both nostrils should be patent, and that the advancement of the scope into the trachea should not compress it due to inadequate space. One more method is by using tube exchangers, if on to the same side,[1 2] and jet ventilation. However, this method requires expertise and can predispose to high failure rates depending on the type of exchanger being used. On the other hand, barotrauma with jet ventilation and tracheobronchial trauma by tube exchanger are a possibility and there have been case reports.[3] The difficult airway can present in the perioperative period even after a seemingly successful intubation, which can end up in an unanticipated difficult intubation setting. Such situations should be handled with utmost caution and in the presence of experienced hands, as loss of airway can lead to perioperative mortality. Conclusion In a difficult airway patient following FOB-assisted intubation through one nostril, the side of nasal tube can be changed after induction by passing FOB through the other nostril to trachea by side of existing ETT. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

              Author and article information

              Saudi J Anaesth
              Saudi J Anaesth
              Saudi Journal of Anaesthesia
              Wolters Kluwer - Medknow (India )
              Apr-Jun 2021
              01 April 2021
              : 15
              : 2
              : 238-239
              Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
              Author notes
              Address for correspondence: Dr. Sohan L. Solanki, Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Dr E Borges Road, Parel, Mumbai - 400 012, Maharashtra, India. E-mail: me_sohans@ 123456yahoo.co.in
              Copyright: © 2021 Saudi Journal of Anaesthesia

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