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Nasogastric Tube Knotted Around a Nasal Endotracheal Tube in the Nasopharynx: Possible Cause
Yunosuke OkadaDDS,
Hanako OhkeDDS,
Hiroyo YoshimotoDDS, PhD,
Misato KobashiDDS,
Masato SaitohDDS, PhD, and
Makoto TerumitsuDDS, PhD
Article Category: Case Report
Volume/Issue: Volume 68: Issue 2
Online Publication Date: Jun 29, 2021
DOI: 10.2344/anpr-67-04-01
Page Range: 90 – 93

within the nasopharynx. We compare this case with previous similar cases and provide a plausible theory as to how the tube might have become knotted. CASE PRESENTATION A 25-year-old man (height 173 cm, weight 62 kg, body mass index 20.7 kg/m 2 ) underwent the removal of 4 third molars under general anesthesia. Other than nasal obstruction and mild tonsillar hypertrophy, the patient had no significant medical history and reported no medications nor any allergies, and he was deemed American Society of Anesthesiologists physical status I

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Petroleum Jelly–Based Foreign Body in the Nasopharynx: A Case Report
Daniel LimDMD, MPH and
Ralph EpsteinDDS
Article Category: Case Report
Volume/Issue: Volume 71: Issue 3
Online Publication Date: Sep 09, 2024
DOI: 10.2344/862982
Page Range: 131 – 135

30-gauge nasopharyngeal airways. A prewarmed, lubricated, cuffed, preformed 7.5-mm nasal ETT (Parker Flex-Tip, Parker Medical) was inserted and advanced into the nasopharynx. Atraumatic video laryngoscopy was then performed and a Cormack-Lehane grade 1 view was observed along with the distal end of the ETT. At this time, a blue foreign body resembling some type of paste material was visualized inside of the ETT approximately 1 cm from its distal tip. After 1 failed attempt to suction out the foreign body, the ETT was removed and examined, revealing a slimy, blue

Figure 1.; Radiographic image of head and neck. Loop of nasogastric tube shown in hypopharynx (white arrow) and knot shown in nasopharynx (black arrow).
Yunosuke Okada,
Hanako Ohke,
Hiroyo Yoshimoto,
Misato Kobashi,
Masato Saitoh, and
Makoto Terumitsu
Figure 1.
Figure 1.

Radiographic image of head and neck. Loop of nasogastric tube shown in hypopharynx (white arrow) and knot shown in nasopharynx (black arrow).

Figure 3.; Model used to theorize how the nasogastric tube (NGT) might have become knotted around the nasal tracheal tube (NETT). (A) The NGT folded and turned backward toward the oropharynx, leading to its appearance in the oral cavity after the first (blinded) intubation attempt. (B, C) The NGT and NETT became entwined and formed a loose knot, although this maneuver was performed under direct vision with forceps. (D) The motion of pulling the NGT (arrow) to move the knot upward toward the nasopharynx led to tight knotting of the NGT to the NETT.
Yunosuke Okada,
Hanako Ohke,
Hiroyo Yoshimoto,
Misato Kobashi,
Masato Saitoh, and
Makoto Terumitsu
Figure 3.
Figure 3.

Model used to theorize how the nasogastric tube (NGT) might have become knotted around the nasal tracheal tube (NETT). (A) The NGT folded and turned backward toward the oropharynx, leading to its appearance in the oral cavity after the first (blinded) intubation attempt. (B, C) The NGT and NETT became entwined and formed a loose knot, although this maneuver was performed under direct vision with forceps. (D) The motion of pulling the NGT (arrow) to move the knot upward toward the nasopharynx led to tight knotting of the NGT to the NETT.

Figure 2.; Nasogastric tube (NGT) tightly knotted to the withdrawn nasal tracheal tube (NETT).
Yunosuke Okada,
Hanako Ohke,
Hiroyo Yoshimoto,
Misato Kobashi,
Masato Saitoh, and
Makoto Terumitsu
Figure 2.
Figure 2.

Nasogastric tube (NGT) tightly knotted to the withdrawn nasal tracheal tube (NETT).

Figure 1.; Foreign Body in the Oropharynx A still image from video laryngoscopy demonstrating the discovery of a blue petroleum jelly–based foreign body. The following parts are marked in the image: (a) epiglottis; (b) distal tip of the nasal endotracheal tube; (c) Yankauer suction tip; (d) uvula; (e) foreign body.
Daniel Lim and
Ralph Epstein
Figure 1.
Figure 1.

Foreign Body in the Oropharynx

A still image from video laryngoscopy demonstrating the discovery of a blue petroleum jelly–based foreign body. The following parts are marked in the image: (a) epiglottis; (b) distal tip of the nasal endotracheal tube; (c) Yankauer suction tip; (d) uvula; (e) foreign body.

Figure 3.; Residual Foreign Body in the Endotracheal Tube (ETT) A still image from video laryngoscopy demonstrating presence of a blue foreign body residue inside the distal tip of nasal ETT. The residue (*) is visualized behind the blue line of the nasal ETT in the lower right quadrant of the image.
Daniel Lim and
Ralph Epstein
Figure 3.
Figure 3.

Residual Foreign Body in the Endotracheal Tube (ETT)

A still image from video laryngoscopy demonstrating presence of a blue foreign body residue inside the distal tip of nasal ETT. The residue (*) is visualized behind the blue line of the nasal ETT in the lower right quadrant of the image.

Figure 2.; Suctioning of the Foreign Body A still image from video laryngoscopy demonstrating the gelatinous nature of the blue foreign body, mimicking a heavy, viscous phlegm. Residual foreign body pieces are visualized on the posterior wall of the oropharynx behind the foreign body and nasal endotracheal tube.
Daniel Lim and
Ralph Epstein
Figure 2.
Figure 2.

Suctioning of the Foreign Body

A still image from video laryngoscopy demonstrating the gelatinous nature of the blue foreign body, mimicking a heavy, viscous phlegm. Residual foreign body pieces are visualized on the posterior wall of the oropharynx behind the foreign body and nasal endotracheal tube.

Figure 1; Anatomical landmarks and definitions of craniofacial dimensions. Definitions of the landmarks : point a  =  eyebrow ; point b  =  the ala nasi ; point c  =  earlobe ; point d  =  mandibular mentum ; point e  =  laryngeal incisure ; point f  =  suprasternal notch ; point g  =  armpit ; point A  =  point that the tracheal tube appears from nasopharynx ; point B  =  tip of the laryngoscope or Airway Scope blade corresponding to the base of the tongue ; point C  =  cricoid cartilage ; point D  =  the point of the extension line that connects the point B and the point C (Laryngeal axis). Definitions of the four lines : Cervical line  =  line that connects the point c and a point of intersection between the surface of the operating table and a perpendicular line through the point g ; Facial line  =  line that connects the point b and the point a ; Surface line  =  surface of the operating table ; Laryngeal axis  =  line that connects the point B and the point C. Definitions of the angles formed by the lines : lower neck flexion angle (α)  =  angle between the cervical line and facial line ; upper neck extension angle (β)  =  angle between the cervical line and the surface line. Definitions of distance : Facial height (X)  =  distance between the point b and the surface line ; Thyromental distance (Y)  =  distance between the point d and the point e ; Sternomental distance (Z)  =  distance between the point d and the point f.
Figure 1
Figure 1

Anatomical landmarks and definitions of craniofacial dimensions.

Definitions of the landmarks : point a  =  eyebrow ; point b  =  the ala nasi ; point c  =  earlobe ; point d  =  mandibular mentum ; point e  =  laryngeal incisure ; point f  =  suprasternal notch ; point g  =  armpit ; point A  =  point that the tracheal tube appears from nasopharynx ; point B  =  tip of the laryngoscope or Airway Scope blade corresponding to the base of the tongue ; point C  =  cricoid cartilage ; point D  =  the point of the extension line that connects the point B and the point C (Laryngeal axis).

Definitions of the four lines : Cervical line  =  line that connects the point c and a point of intersection between the surface of the operating table and a perpendicular line through the point g ; Facial line  =  line that connects the point b and the point a ; Surface line  =  surface of the operating table ; Laryngeal axis  =  line that connects the point B and the point C.

Definitions of the angles formed by the lines : lower neck flexion angle (α)  =  angle between the cervical line and facial line ; upper neck extension angle (β)  =  angle between the cervical line and the surface line.

Definitions of distance : Facial height (X)  =  distance between the point b and the surface line ; Thyromental distance (Y)  =  distance between the point d and the point e ; Sternomental distance (Z)  =  distance between the point d and the point f.

Thermophysical Properties of Thermosoftening Nasotracheal Tubes
Yoshihiro TakasugiDDS, PhD,
Koichi FutagawaMD, PhD,
Takashi UmedaPhD,
Kouhei KazuharaME, and
Satoshi MorishitaMS
Article Category: Research Article
Volume/Issue: Volume 65: Issue 2
Online Publication Date: Jan 01, 2018
DOI: 10.2344/anpr-65-02-06
Page Range: 100 – 105

and adjacent septum are common (>50%), postoperative rhinoscopy did not detect any significant injury in patients who had epistaxis. 1 Since the posterior wall of the nasopharynx, which has recesses and the pharyngeal tonsils, is an area of loose tissue, impingement of the tip of a nasotracheal tube (NTT) on the posterior wall of the nasopharynx can lead to nasopharyngeal laceration or potentially more severe complications. 7 , 8 Clinically relevant bleeding related to nasotracheal intubation has been reported in 27.5% 9 and 52% 4 of cases when evaluated by