A hybrid nasal intubation technique for the head and neck surgical patient: a case series and review of the literature

Abstract

Purpose The inherent morbidity associated with intubation, especially nasal intubation, is well documented in the literature. Risks include vocal cord trauma, arytenoid dislocation, and trauma throughout the nasopharynx and the larynx. Furthermore, repeated intubation attempts are associated with increased patient morbidity and mortality. The head and neck surgical patient poses a unique challenge to the anesthesiologist, presenting with a difficult airway in addition to often requiring nasal intubation for surgical access. This case report series evaluates a hybrid technique that applies existing difficult airway strategies as a standard combined approach in the head and neck surgical patient without trismus. Nasal intubation is achieved with direct laryngoscopy, with or without the assistance of Magill forceps, fiberoptic scopes, and video laryngoscopes, to minimize nasopharyngeal trauma. Our method combines the standard armamentarium for rescue techniques into a hybrid approach. Methods Once anesthesia is induced and after topicalization with lidocaine and oxymetazoline, a nasal Ring-Adair-Elwyn (RAE) endotracheal tube is passed through the favorable nostril and into the nasopharynx. The video laryngoscope is next used to visualize the glottis. Once the tip of the nasal RAE is advanced and visualized near the glottic opening, a fiberoptic scope is passed through the nasal RAE. Two video screens are used simultaneously to guide the fiberoptic scope and subsequently the endotracheal tube through the glottis. Results The 3 patients described in this article were successfully intubated by using this approach, without the use of Magill forceps. This resulted in minimal trauma, fewer intubation attempts, and comparable intubation time. Conclusions Although neither the constituents nor the techniques are unique, they are usually reserved as mutually exclusive rescue measures for managing the difficult airway. We believe this hybrid technique may become the standard of care for the majority of head and neck surgical patients requiring nasal intubation. This decreases the risk of nasopharyngeal and laryngeal trauma and does not increase cost because the video laryngoscope and the fiberoptic scope are standard equipment available in most hospitals. This approach may decrease patient morbidity and reduce total intubation time.