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Year : 2012  |  Volume : 56  |  Issue : 4  |  Page : 433  

A rare potentially hazardous malposition of the nasotracheal tube

Department of Anaesthesiology, Government Medical College and Government General Hospital, Anantapur, Andhra Pradesh, India

Date of Web Publication8-Sep-2012

Correspondence Address:
Kalavala Lakshminarayana Subramanyam
Associate Professor of Anaesthesiology, #202, Rajahamsa Rainbow Apartments, Aravindanagar, 1st Cross, Anantapur - 515 001, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5049.100853

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How to cite this article:
Subramanyam KL, Murthy MS. A rare potentially hazardous malposition of the nasotracheal tube. Indian J Anaesth 2012;56:433

How to cite this URL:
Subramanyam KL, Murthy MS. A rare potentially hazardous malposition of the nasotracheal tube. Indian J Anaesth [serial online] 2012 [cited 2020 May 25];56:433. Available from:


We have read with interest the article of Murali Chakravarthi et al. "A rare potentially hazardous malposition of the nasotracheal tube" published in IJA (Vol 56/Issue 1/2012).

We are happy to note that the authors are lucky enough for the successful outcome of the case. Likewise, we would like to address the basis of selection of the type of anaesthesia especially in such a patient posted for hip surgery.

The patient is an obese [1] male and also a chronic and heavy smoker having COPD. [2] He gives H/o Obstructive sleep apnea [3] having to use CPAP mask during nights. His airway assessment shows Mallampati grade 3 with short neck and limited extension of the neck. All the above features favoured difficult intubation. This patient was operated for Hip Arthroplasty under GA.

We are surprised why the authors did not considerregional anaesthesia at all in such a patient. The reason for opting General Anaesthesia instead of regional anaesthesia (which is safe, easy, simple and economical) [4],[5] by the authors could not be justified or substantiated.

Secondly, selection of Nasotracheal intubation over conventional orotracheal intubation in a patient with difficult airway using fibreoptic bronchoscopic technique, that too without completely anaesthetizing the airway. This may be the reason for the severe cough which the patient had while the authors attempted intubation. "Blocks of supralaryngeal nerves bilaterally along with translaryngeal injection of local anaesthetic provides anaesthesia of airway from infraglottic area to the epiglottis" as described by Miller. [6]

Another reason which we feel that the authors could have gone for oral intubation should be to use a large endotracheal tube rather that nasal intubation with small ETT which has high resistance. The authors have not mentioned the resistance encountered by them using the small ETT for that age and weight of the patient.

For all the above reasons, we feel that the authors have violated the basic teachings of anaesthesia regarding the selection of the technique and choice of anaesthesia.

   References Top

1.Adams JP, Murphy PG. Obesity in anaesthesia and intensive care. BJA 2000;85:91-108.  Back to cited text no. 1
2.Raun MB. Comparison of spinal and general anaesthesia for lower abdominal surgeries in patients with COPD. Anaesthesiology 1971;35:319-22.  Back to cited text no. 2
3.Hiremath AS, Hillman DR, James AL, Noffsinger WJ, Platt PR, Singer SL. Relation between difficult intubation and obstructive sleep apnea. BJA 1998;80:606-11.  Back to cited text no. 3
4.Davis FM, Woolner DF, Frampton C, Wilkinson A, Grant A, Harrison RT, et al. Multicenter trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly. BJA 1987;59:1080-88.  Back to cited text no. 4
5.Mckenzie PJ, Wishart HY, Dewar KMS, Gray I, Smith G. Comparision of effects of spinal anaesthesia and general anaesthesia on postop oxygenation and perioperative mortality. BJA 1980;52:49-53.  Back to cited text no. 5
6.Ronald D Miller. Text book of Anaesthesia 5 th edition; Vol. 1: P. 1541.  Back to cited text no. 6

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1 Comment: Hard palate tumour: A nightmare for the anaesthesiologists: Role of modified molar approach
Subramanyam, K.L.
Indian Journal of Anaesthesia. 2013; 57(4): 432-433


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