Nasal intubation in an adult male with Le Fort II fracture and pneumocephalus using a nasogastric tube.

Sir,

We present here the difficulties encountered in an adult patient with Le Fort II fractures and head injury for open reduction/internal fixation of mandible, which arose due to non-availability of an adult fibreoptic bronchoscope (FOB) and bougie. Patient had Glasgow coma scale score 15/15 with normal vitals, blood parameters and cervical spine. Computed tomography scan showed a small subdural hematoma and pneumocephalus in the right temporal region with no significant midline shift, Le Fort II fracture (left), bilateral fracture body and condyle mandible; comminuted fracture of frontal/maxillary sinuses, orbit and nasal septum, which was deviated to the right [Figure 1]. Edematous inferior turbinates were seen bilaterally, left nasal passage diameter being grossly narrowed. Airway assessment revealed an interincisor distance of 1.5 cm with complaint of pain in the jaw. The rest of the airway was normal.

Figure 1

Computed tomography face/paranasal sinuses

Blind nasotracheal intubation (NTI) is contraindicated in Le Fort II and III fractures.[1] So in such patients a proper sized FOB and a well-equipped difficult airway trolley are indispensable. An awake fibreoptic NTI was planned in our case. The backup plan was NTI with direct laryngoscopy and spontaneous ventilation if the mouth opening improved on induction. Submental intubation was also considered, but it might not be possible because of the limited mouth opening and bilateral mandible fractures. Tracheostomy would be the last resort.

Unfortunately for us, the adult FOB was found to be non-functional and the bougie was missing. After preparing the patient's airway, a paediatric FOB (Pentax) was passed through the right nasal passage. Glottis was well-visualised. After this, we attached a 7.0 mm internal diameter (ID) endotracheal tube (ETT) (cut up to 28 cm mark) on the FOB. We tried to negotiate the FOB along with the tube as the length of the FOB remaining beyond the tip of ETT was just about 2.5 cm, which is barely enough for manoeuvring the FOB tip. A bony resistance was felt at a depth of 4-5 cm. The short (30 cm) FOB could not be inserted any further without the tube. The attempt was repeated with a 6.5 mm ETT albeit unsuccessfully. We did not want to push in the tube to avoid trauma. ETT of 6 mm ID or less would be too short for NTI and fixation in the adult. Inability to pass the ETT beyond the resistance made the absence of the adult fibrescope seem a real setback. The remaining option was NTI with laryngoscopy after induction of anaesthesia with sevoflurane, provided mouth opening would improve after induction. This was tried after checking mask fit. Gentle mask ventilation was performed to avoid aggravation of pneumocephalus.[2] We now thought of passing a bougie-like device beyond the resistance and then railroad the ETT over it, even if it meant pushing in the tube. Even though, there was no guarantee that the subsequent blind passage of the nasogastric tube (NGT) would be entirely safe, a 14 french gauge NGT was now inserted into the nasopharynx as the nasal passage had already been confirmed with the FOB. A 6.5 mm ID ETT was threaded over the NGT. When the patient was deep, direct laryngoscopy was performed. The NGT was then advanced into the larynx with a Magill's forceps and the ETT was inserted in the trachea. This time, we did not hesitate to push the tube inside with slight force against the resistance for two reasons. Firstly, minimal bleed hampering FOB vision was no longer a concern. Secondly, securing the airway in case of a bleed could be managed better with the ETT already railroaded over the NGT which was in the larynx. Tracheostomy could thus be avoided and surgery could be completed. Unavailability of different equipments at different times is not uncommon in the Indian scenario. Hence, there is a constant need to innovate.