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Nasogastric Tube Knotted Around a Nasal Endotracheal Tube in the Nasopharynx: Possible Cause
Yunosuke Okada DDS,
 Hanako Ohke DDS,
 Hiroyo Yoshimoto DDS, PhD,
 Misato Kobashi DDS,
 Masato Saitoh DDS, PhD, and
 Makoto Terumitsu DDS, 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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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; 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 Takasugi DDS, PhD,
 Koichi Futagawa MD, PhD,
 Takashi Umeda PhD,
 Kouhei Kazuhara ME, and
 Satoshi Morishita MS
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

Retropharyngeal Dissection by Parker Flex-Tip Nasal Endotracheal Tube
Makoto Terumitsu DDS, PhD,
 Mikiko Hirahara DDS, and
 Kenji Seo DDS, PhD
Article Category: Case Report
Volume/Issue: Volume 64: Issue 4
Online Publication Date: Jan 01, 2017
DOI: 10.2344/anpr-64-03-05
Page Range: 240 – 243

2 ). We then inspected the pharynx with a fiberscope and found no severe damage to the nasopharynx. An otolaryngologist subsequently examined the patient by fiberscope and found no severe bleeding in the epipharynx. The otolaryngologist removed a coagulum by suction but could not identify the exact site at which the tube had invaded the mucous membrane. The bleeding did not persist. Ultrasonographic examination revealed no findings of emphysema or hematoma in the neck. Because the dissected lesion was difficult to suture, we treated the patient with intravenous

Thermosoftening of the Parker Flex-TipTM Tracheal Tube in Preparation for Nasotracheal Intubation
Takuro Sanuki DDS, PhD and
 Junichiro Kotani DDS, PhD
Article Category: Other
Volume/Issue: Volume 60: Issue 3
Online Publication Date: Jan 01, 2013
DOI: 10.2344/0003-3006-60.3.109
Page Range: 109 – 110

is thermosoftened prior to nasotracheal intubation. During nasotracheal intubation, the distal tip of the endotracheal tube is inserted through the naris into the oropharynx. At this point, the endotracheal tube can impinge on the posterior wall of the nasopharynx, where the nasal passage turns acutely. 6 The soft distal tip of the PFTT becomes softer with thermosoftening, 7 and may easily collapse upon impact. Xue et al 8 described how the PFTT may collapse upon impact, even if it has not been thermosoftened. We suspect that the tip of a thermosoftened

Modified Retrograde Nasal Intubation: A New Airway Technique and Devices
Vernon H. Vivian MBChB,
 Dip Anaes (SA),
 Tyson L. Pardon MD, and
 Andre A. J. Van Zundert MD, PhD, EDRA
Article Category: Research Article
Volume/Issue: Volume 68: Issue 2
Online Publication Date: Jun 29, 2021
DOI: 10.2344/anpr-68-02-03
Page Range: 107 – 113

A century ago, in 1920, Magill and Rowbotham 1 pioneered the concept of nasotracheal intubation (NTI). By blindly inserting a red rubber oral tube with a lateral bevel through the nostril and using Magill forceps to direct the tube into the trachea, they provided a ground-breaking airway management solution for many surgical interventions requiring concurrent access to the oral and maxillofacial complex. NTI is a safe technique in skilled hands; however, the passage of a bevelled endotracheal tube (ETT) through the nasopharynx may

Partially Withdrawn Nasotracheal Tube: An Alternative to the Nasal Trumpet
Yong Hee Park MD, MSD,
 Young Jun Choi DDS, PhD,
 Won Cheul Choi DDS, PhD, and
 Ui Lyong Lee DDS, MSD
Article Category: Research Article
Volume/Issue: Volume 62: Issue 4
Online Publication Date: Jan 01, 2015
DOI: 10.2344/15-00013.1
Page Range: 166 – 167

clots filling nasal cavity. Inspired by previous success in keeping the nasal airway patent with the NPA in the immediate postoperative period of bimaxillary orthognathic surgery, we partially withdrew the ETT (Mallinckrodt Nasal RAE) to allow the tube to remain in the nasopharynx after deflating the cuff ( Figure 1 ). The ETT was cut and the standard adaptor supplied with the ETT was reinserted into the proximal end ( Figure 2 ). The partially withdrawn and shortened ETT performed like a NPA allowing supplemental oxygen to be provided but also allowed pharyngeal