Nasal septal perforation diagnosed intraoperatively by course of nasotracheal tube from left nostril to right nostril.

Sir,

A 28-year-old man was posted for right medial maxillectomy under general anaesthesia following recurrence of poorly differentiated neuroendocrine carcinoma of the right ethmoidal sinus. Three months before, he had undergone complete excision of the tumour and had received three cycles of etoposide and carboplatin after surgery. Physical examination did not reveal any gross abnormality in the upper airway.

The surgery required endotracheal tube placement through the left nostril. The left nasal passage was prepared with xylometazoline nasal drops and 2% lignocaine jelly. Anaesthesia was induced with fentanyl, propofol and rocuronium. The nasal passage was dilated using a 7.0 size nasopharyngeal airway. A Portex® 7.0 mm internal diameter (ID) cuffed endotracheal tube lubricated with 2% lignocaine jelly was then introduced into the left nostril with the bevel facing the turbinates and passed posteriorly all along into the hypopharynx. Slight resistance was encountered during its passage through the nasal cavity. Once it entered the oropharynx, the movements became smooth. On direct laryngoscopy, there was a little blood in the oropharynx. Visualisation of the epiglottis was not difficult and it corresponded to Cormack–Lehane Grade 1 view. The tracheal tube was passed beyond the vocal cords and the cuff was inflated. Tracheal placement of the tube was confirmed using capnography. During surgery, during endoscopy-assisted excision of tumour around the posterior wall of maxilla, pterygoid region and anterior wall of sphenoid, the endotracheal tube was seen to be on the right side [Figure 1a–c]. While tracing it backwards, it was revealed that the tube which was inserted through the left nostril had passed across the nasal septum to enter the right side and then further went ahead. There was no active bleeding from that site or any difficulty in ventilating the patient. After excision of tumour, surgeons decided to pack the right nasal cavity. Hence, the nasotracheal tube was removed and trachea was intubated with a new 8.0 mm ID oral endotracheal tube. The rest of the intra- and post-operative course was uneventful.

Figure 1

(a) Endotracheal tube passage through left nostril, (b and c) endotracheal tube entering in the right nostril after perforation of septum, (d) magnetic resonance imaging image showing the recurrence of disease and thinning of nasal septum

Nasotracheal intubation is one of the most common methods used to secure airway in surgery of maxillofacial region as it gives good accessibility and visibility for oral surgical procedures. Several complications during nasotracheal intubation such as haemorrhage,[1] partial turbinectomy[23] and total turbinectomy[4] have been reported in the past.

Deviated nasal septum, presence of angulated septum and bony spurs increase the risk of trauma due to the pressure applied for intubation. Prior endoscopic nasal surgery could lead to a small rent in the nasal septum which may increase in size due to the pressure during passage of the tube through the nose leading to septal perforation.

In the present case, septal perforation probably occurred at the time of intubation, but it was discovered during surgery. The exact cause for septal perforation is not known, but it could be due to the presence of rent in the septum preoperatively because of prior surgery, or thinning of the septum due to disease process [Figure 1d] that lead to septal perforation when pressure was applied while introducing the nasotracheal tube through the nostril.

A detailed pre-anaesthetic evaluation inclusive of intranasal abnormality is important for prevention of such complications. Whenever, there is difficulty in passing the tube through nostril, and more than threshold pressure is required, it is always safer to use another nostril.[5] Application of below threshold pressure at the time of intubation and using fibre-optic bronchoscope for nasal intubation in at-risk patients can help in preventing such complications.[5] Fibre-optic anterior rhinoscopy allows for initial assessment of any pre-operative abnormalities especially in patients who have undergone prior nasal surgeries.

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