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Table of Contents
Year : 2022  |  Volume : 15  |  Issue : 2  |  Page : 108-111

Ryles tube-guided difficult nasal intubation

Department of Anaesthesia and Pain Management, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India

Date of Submission23-Feb-2022
Date of Decision30-Mar-2022
Date of Acceptance01-Apr-2022
Date of Web Publication04-Jul-2022

Correspondence Address:
K Bineetha
Department of Anaesthesia and Pain Management, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hmj.hmj_23_22

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Rationale: Nasal intubation is an inevitable procedure in head and neck and oral cavity surgeries. Most of these patients usually present with distorted oral and nasal anatomy. Patient Concerns: The distorted anatomy in these patients makes their airway difficult and there are high chances of nasal bleed while securing the airway nasally. Diagnosis: Ryle's tube guided nasal intubation in a patient with temporomandibular joint derangement posted for bilateral temporomandibular joint arthrocentesis. Interventions: After induction of anaesthesia, we faced difficulty in passing North Pole tube via nasal passage, hence we rail roaded the North Pole tube over a Ryle's tube and successfully secured the airway. Outcomes: This innovative method helped us to secure the airway in this patient. Lessons: This simple technique of using a Ryle's tube as an aid for nasal intubation provides an alternate technique for difficult nasal intubation. Although it may not be the first choice for nasal intubation, this technique can be used as an alternative method in case, the tube could not be negotiated through the nasal passage.

Keywords: Difficult nasotracheal intubation, RYLE'S tube, TMJ ankylosis, video laryngoscope

How to cite this article:
Bineetha K, Koli DC, Mandal T, Mehta HH. Ryles tube-guided difficult nasal intubation. Hamdan Med J 2022;15:108-11

How to cite this URL:
Bineetha K, Koli DC, Mandal T, Mehta HH. Ryles tube-guided difficult nasal intubation. Hamdan Med J [serial online] 2022 [cited 2022 Aug 10];15:108-11. Available from: http://www.hamdanjournal.org/text.asp?2022/15/2/108/349778

  Introduction Top

Since the first orotracheal intubation in 1878 using a blind digital technique, airway management in anaesthesia has come a long way;[1] with the invention of the intubating fibre-optic bronchoscope (FOB), first described in 1967 by peter murphy;[2] Anaesthesia practices in difficult airway management have advanced significantly. FOB-guided awake intubation is considered the gold standard in anticipated difficult airway management in current anaesthesia practices;[3] but despite all the developments in airway equipment and techniques, mistakes in airway assessment and proper planning persist, which could result in life-threatening consequences.

In case of patients with restricted mouth opening, different techniques for nasal intubation are as follows: awake blind nasal intubation, retrograde intubation, fibre optic guided intubation and tracheostomy. Out of which FOB guided intubation is the safest technique.

In our case, despite bilateral TM joint involvement, our patient had adequate mouth opening. However, due to severely deviated nasal septum, we had difficulty in negotiating the tube through the nasal passage; hence, we tried an innovative technique of railroading the North Pole tube over RYLE'S tube with a positive result. Hence, we tried the same technique in other patients where the nasal passage was small and in case of deviated nasal septum and we were easily able to pass the North Pole tube over RYLE'S tube avoiding multiple attempts in the blind passage of North Pole nasally and limiting trauma to the nasal passage.

  Case Report Top

A 34-year-old female of weight 59 kg, height 162 cm and BMI 22.5 kg/m2 presented with the chief complaints of pain in bilateral temporomandibular joint (TMJ) for 2 years, clicking sound while mouth opening and maligned teeth. She had a history of occasional locking of the TMJ. The patient was diagnosed to have internal derangement of TMJ and was posted for arthrocentesis of bilateral TMJ. The patient was a known case of hypothyroidism on tablet thyronorm 12.5 mcg once a day.

On airway examination, the patient had retrognathia, adequate mouth opening, was wearing permanent braces, Mallampati class 3, thyromental distance of 6 cm with normal neck movements in flexion, extension and side-to-side movements.

On general physical examination, pulse rate was 86 bpm, blood pressure in supine position was 122/92 mm hg and Spo2 of 100% on room air.

The primary plan of action was to secure the airway under ideal circumstances with an intravenous induction and short-acting muscle relaxant, followed by nasal intubation using a North Pole tube with the assistance of a video laryngoscope. In case of any difficulties in passing the tube, small-sized North Pole tubes, flexometallic tubes and normal endotracheal tubes were kept ready. FOB was also kept on standby. A difficult airway cart was kept ready inside the operation theatre (OT).

Considering difficult airway, the patient was explained and counselled in detail about nasal intubation and complications associated with it on the day before the surgery and written informed consent was obtained. The patient was kept nil by mouth since midnight, In the pre-operative room, both nostrils were packed with nasal patties soaked with 2% lignocaine and adrenaline and oxymetazoline nasal drops, and a wide bore IV cannula was secured. Once inside OT, all standard ASA monitors were attached, baseline pulse rate was 81/min, blood pressure of 140/80 mm hg and SpO2 100% on room air. O2 was started at 4 L/min via a nasal prong. 2% lignocaine jelly was applied in both nostrils one after the other and patient was asked to inhale deeply to check for the patency, of which nostril is better to pass the North Pole tube. The right nostril was found to be more patent. The patient was pre-oxygenated with 100% oxygen. After checking and keeping the airway trolley fully ready, injection midazolam 1 mg, injection of fentanyl 50 mcg and injection propofol 120 mg were given. Once the patient was under anaesthesia check ventilation was done and after confirming that patient was getting ventilated properly, injection of succinylcholine 75 mg was given. We tried to intubate with 6 number North Pole tube through the right nostril, but the tube was not going beyond the nasal cavity, so then tried passing the tube through the left nostril, which was also not successful. The patient was ventilated again and then tried passing a normal endotracheal tube of size no. 5.5 and 5 through both the nostrils, which also failed. Attempts to pass a nasopharyngeal airway also did not succeed. Since the patient was vitally stable throughout without any drop in saturation and was getting ventilated properly, there was no situation of panic. After mask ventilating the patient for another 3 min, a 14 Fr RYLE'S tube [with the upper green end cut: [Figure 1]] was inserted through the right nostril [Figure 2] which was passed freely and a north pole tube number 6 was then railroaded over it [Figure 3]. With the assistance of video laryngoscope, the tube was passed into the trachea [Figure 4]. RYLE'S tube was then removed from the ET tube and the position of the ET tube was confirmed by ETCO2 tracing and equal air entry on both sides of the chest on auscultation. The patient was then given injection cisatracurium 10 mg and injection fentanyl 50 mcg. During intraoperative period, anaesthesia was maintained with O2/ air (50:50) and desflurane mixture (MAC kept between 0.9-1) along with atracurium infusion (5 mg/ml) at the rate of 20mg/hr and dexmedetomidine (2 mcg/ml) titrated between 0.2-0.5 mcg/kg/hr. The patient was haemodynamically stable throughout the surgery. Bilateral TMJ arthrocentesis was done uneventfully.
Figure 1: 14 Fr Ryle's tube

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Figure 2: Ryle's tube insertion via right nostril

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Figure 3: Rail roading north pole tube over Ryle's tube

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Figure 4: Video laryngoscopy guided north pole tube insertion

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Post-surgical closure once the patient was fully conscious and had good spontaneous breathing efforts, neuromuscular blockade reversed with injection neostigmine 2.5 mg and injection glycopyrrolate 0.5 mg. Thorough suctioning of the oropharynx was done and the patient was extubated once all extubating criteria were met. The patient was breathing normally and was maintaining a saturation of 100% with O2 @ 6 L/min via a Hudson mask. She was observed inside the OT for half an hour for any signs of desaturation or haemodynamic instability and then was shifted to PACU. She was kept on observation for an hour in PACU and then shifted to the ward. She was haemodynamically stable and was maintaining an SPO2 of 100% on room air. The patient was followed up in the evening and was found to be stable throughout. The patient was discharged on the post-operative day 2.

  Discussion Top

Kuhn described nasal intubation for the first time in 1902 Rosenberg, Meltzer, Macewen and Auer and Elsberg were among those who pioneered the technique.[4] when intraoral surgical access is required it is commonly used for anaesthesia in oral, maxillofacial, head-and-neck surgeries. Direct laryngoscopes such as the Macintosh, McCoy or video laryngoscopes are typically used for nasotracheal intubation.[5]

Other nasal intubation techniques include retrograde endotracheal intubation, bi-nasopharyngeal airway, semi-blind nasal intubation and a fluoroscope-aided retrograde placement of the guidewire for the tracheal intubation and tracheostomy and fibre-optic-guided awake intubation.

During nasotracheal intubation, the patient's neck must be extended and Magill's forceps may be used to guide the tip of the endotracheal tube into the glottis or cuff inflation technique, in which the tubes cuff is sequentially inflated with 10–15 ml air till the tip of the tube is near the glottis opening then the cuff is deflated and tube passed further into the larynx.

Some of the complications associated with nasotracheal intubation are epistaxis, bacteraemia and partial or complete obstruction of the tube.[6],[7] The most common complication is epistaxis, which can endanger a patient's life if blood aspirates into the lung and these complications are increased by abnormal nasal anatomy and multiple attempts at nasal intubation.

TMJ disorder is commonly associated with restricted mouth opening and difficult airway;[8]

The prediction of difficult airways is critical for patient safety and the avoidance of complications. Mouth opening, Mallampati scores, thyromental and sternomental distances were among the airway tests used.

In our case, though the patient had a history of bilateral TMJ ankylosis, the mouth opening was adequate. Hence, the primary plan for securing the airway was nasal intubation using a North Pole tube with the assistance of a video laryngoscope. In case of difficulty in plan A, then plan B was to do oral intubation under GA. However, we had difficulty in passing the tube beyond the nasopharynx due to deviated nasal septum and even with no 5 cuffed endotracheal tube, we were not able to negotiate the nasal passage; hence, we tried a novel method by passing 14 Fr RYLE'S tube first via the right nostril and then, no 6 north pole was passed over it without much difficulty. In case of failure to pass the tube nasally, our plan was to do videolaryngoscope-guided oral intubation as the patient had adequate mouth opening. Post nasal intubation, the surgery went well and the rest of the intraoperative period was uneventful. Hence, we extubated the patient on the operation table and discharged her with stable haemodynamic on the post-operative day 2.

  Conclusion Top

Nasotracheal intubation is an effective and safe technique that is underutilised in modern medicine. The benefits of a patient intubated via the nasal route to a head-and-neck surgeon may exceed the few disadvantages. Although this technique may not be the first choice for nasotracheal intubation, it can be used as an alternative technique, in case the tube cannot be negotiated through the nostril so that multiple attempts can be avoided in passing the tube blindly through the nose, resulting in less trauma to nasal structures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Szmuk P, Ezri T, Evron S, Roth Y, Katz J. A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age. Intensive Care Med 2008;34:222-8.  Back to cited text no. 1
Murphy P. A fibre-optic endoscope used for nasal intubation. Anaesthesia 1967;22:489-91.  Back to cited text no. 2
Heidegger T, Gerig HJ. Algorithms for management of the difficult airway. Curr Opin Anaesthesiol 2004;17:483-4.  Back to cited text no. 3
Chauhan V, Acharya G. Nasal intubation: A comprehensive review. Indian J Crit Care Med 2016;20:662-7.  Back to cited text no. 4
[PUBMED]  [Full text]  
Ono K, Goto T, Nakai D, Ueki S, Takenaka S, Moriya T. Incidence and predictors of difficult nasotracheal intubation with airway scope. J Anesth 2014;28:650-4.  Back to cited text no. 5
Hall CE, Shutt LE. Nasotracheal intubation for head and neck surgery. Anaesthesia 2003;58:249-56.  Back to cited text no. 6
Prasanna D, Bhat S. Nasotracheal intubation: An overview. J Maxillofac Oral Surg 2014;13:366-72.  Back to cited text no. 7
Yunus AA, Fomete B, Aghadi IK, Yakubu H. Airway management of patients with temporomandibular joint disorder: A 12-year retrospective review in ABUTH Zaria. Arch Med Surg 2018;3:56-8.  Back to cited text no. 8
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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