Alternative Technique for Nasotracheal Intubation Using a Flexible Fiberoptic Scope
In oral maxillofacial surgery, the endotracheal tube (ETT) is often inserted nasotracheally to provide surgeons a better view and easier access to the oral cavity. Use of a flexible fiberoptic scope is an effective technique for difficult intubation. While the airway anatomy can be observed as the scope is advanced, the ETT tip cannot be observed with the traditional method. It is occasionally difficult to advance the ETT beyond the glottis as impingement of the ETT tip may occur. We devised a new nasotracheal intubation technique using a fiberoptic scope. In this novel technique, the ETT and fiberoptic scope are inserted into the pharyngeal space separately through the right and left nasal cavities. This permits continuous observation of the glottis as the ETT is advanced into the trachea. The main advantage of this technique is that the ETT tip is visualized as it is advanced, which helps avoid impingement of the ETT. If resistance is noted, the ETT can easily be rotated or withdrawn without causing laryngeal damage, leading to safe and smooth intubation. This novel technique allows advancement of the ETT under continuous indirect vision, thus minimizing contact of the ETT with the laryngeal structures and aiding in unhindered passage into the glottis.

Fiberoptic view during nasotracheal intubation using the traditional fiberoptic scope technique (a, b) and our new technique (c). (a) Indirect visualization of the glottis prior to advancement of the endotracheal tube (ETT). (b) Tip of the ETT as it is advanced blindly along the fiberoptic scope. Passage through the glottis cannot be visually confirmed, so the ETT could become impinged upon on a trachea ring or laryngeal anatomy.
(c) Advancement of the ETT through the glottis under continuous indirect visualization.
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