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Correspondence  |   May 2000
Middle Turbinectomy: A Complication of IMPROPER Nasal Intubation?
Author Notes
  • Emeritus
  • Department of Anesthesiology
  • Virginia Mason Medical Center
  • Seattle, Washington
Article Information
Correspondence
Correspondence   |   May 2000
Middle Turbinectomy: A Complication of IMPROPER Nasal Intubation?
Anesthesiology 5 2000, Vol.92, 1504. doi:
Anesthesiology 5 2000, Vol.92, 1504. doi:
To the Editor:—
Despite Williams et al.  not being aware of an unintentional middle turbinectomy occurring during nasotracheal intubation, 1 it has been reported and discussed—albeit not with a 6.0 cuffed RAE endotracheal tube (Mallinckrodt Medical, St. Louis, MO)—in Anesthesiology. 2,3 
I am particularly interested in the details of how the RAE was inserted from the nares into the nasopharynx. Williams et al.  stated it was inserted “into the patient’s right nares with the bevel of the tube facing medially.” This is a bit ambiguous. Is the bevel the point or flat part (opening at the end of the RAE)? What was the opening “facing medial to”— the nasal septum or the turbinates? Was it inserted with the anesthesiologist standing or sitting cephalad to the patient’s head? Lastly, but in all probability most important, was the RAE pulled cephalad at its acute angle (16–17.5 cm markings) after being inserted into the nares and while being passed into the nasopharynx?
Regardless of the type of nasotracheal tube used, turbinectomy is an avoidable complication if: (1) before anesthesia, the turbinates are shrunk using cocaine (4–10%) or a lidocaine-phenylephrine mixture 4,5; (2) when inserting the tube into the nares, its tip lies alongside (parallel) to the nasal septum with the opening in the bevel facing the turbinates, and (3) maintaining this position, it is pulled cephalad as it is passed posteriorly into the nasopharynx. Pulling the nasotracheal
tube cephalad (fig. 1),
Fig. 1. Nasal tracheal intubation showing: (1) the tip of the nose being pulled cephalad as the bevel of the tube is placed through the nares, and (2) the tube being pulled cephalad as it is advanced along the floor of the nasal cavity.
Fig. 1. Nasal tracheal intubation showing: (1) the tip of the nose being pulled cephalad as the bevel of the tube is placed through the nares, and (2) the tube being pulled cephalad as it is advanced along the floor of the nasal cavity.
Fig. 1. Nasal tracheal intubation showing: (1) the tip of the nose being pulled cephalad as the bevel of the tube is placed through the nares, and (2) the tube being pulled cephalad as it is advanced along the floor of the nasal cavity.
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more likely than not directs its bevel and tip away from the turbinates and promotes their passing between the inferior turbinate and the nasal surface of the palate where the nasal passage is the largest. This, in itself, avoids turbinectomy even with a REA tube which if not pulled cephalad is likely to be directed at the turbinates.
References
Williams AR, Burt N, Warren T: Accidental middle turbinectomy: a complication of nasal intubation. A nesthesiology 1999; 90:1782–4Williams, AR Burt, N Warren, T
Cooper R: Bloodless turbinectomy following blind nasal intubation. A nesthesiology 1989; 71:469Cooper, R
Moore DC, Cooper R: Bloodless turbinectomy following blind nasal intubation: faulty technique (letters)? A nesthesiology 1990; 73:1057Moore, DC Cooper, R
Goss JB, Hartigan ML, Shaffer DW: A suitable substitute for 4% cocaine before blind nasotracheal intubation: 3% lidocaine - 0.25% phenylephrine nasal spray. Anesth Analg 1984; 63:915–18Goss, JB Hartigan, ML Shaffer, DW
Sessler CN, Vitaliti JC, Cooper KR, Jones JR, Powell KD, Pesko LJ: Comparison of 4% lidocaine/0.5% phenylephrine with 5% cocaine: which dilates the nasal passages better. A nesthesiology 1986; 64:274–77Sessler, CN Vitaliti, JC Cooper, KR Jones, JR Powell, KD Pesko, LJ
Fig. 1. Nasal tracheal intubation showing: (1) the tip of the nose being pulled cephalad as the bevel of the tube is placed through the nares, and (2) the tube being pulled cephalad as it is advanced along the floor of the nasal cavity.
Fig. 1. Nasal tracheal intubation showing: (1) the tip of the nose being pulled cephalad as the bevel of the tube is placed through the nares, and (2) the tube being pulled cephalad as it is advanced along the floor of the nasal cavity.
Fig. 1. Nasal tracheal intubation showing: (1) the tip of the nose being pulled cephalad as the bevel of the tube is placed through the nares, and (2) the tube being pulled cephalad as it is advanced along the floor of the nasal cavity.
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