"Two-hand-manoeuver" during nasotracheal intubation.

Sir,

Nasotracheal intubation is the mainstay of airway management in oral and facial surgeries. Normally, nasotracheal intubation can be done with no or little difficulties, but sometimes, there may be some difficulty in passing tracheal tube through the nasal passage or passing beyond the epiglottis into the trachea.

After passing through the nasal cavity, tracheal tube may impinge on laryngeal structures.[1] Induction of general anesthesia may approximate the soft palate; tongue and epiglottis to the posterior pharyngeal wall and tracheal tube mostly impinge on epiglottis, right arytenoid, or interarytenoid.[2] During flexible fibreoptic intubation when tracheal tube impinge on this structure, it was shown that a 90° counterclockwise rotation of tube usually helps in the smooth advancement of the tracheal tube into the trachea.[2]

For a normal nasotracheal intubation, having problem of tracheal tube impingement at epiglottis, right arytenoids, interarytenoid, or other laryngeal structures, we here propose a simple maneuver (“Solanki-two-hand maneuver”) where an assistant anesthetist holds the larynx or can give backward, upward, and rightward pressure with left hand and rotates the tracheal tube 90° counterclockwise with the right hand and advances tracheal tube into the trachea under vision of a videolaryngoscopy performed by main anesthetist [Figure 1a–c]; or if direct laryngoscopy by a Macintosh laryngoscope is performed, the main anesthetist performing direct laryngoscopy can see the tracheal tube impingement and subsequent passing the tracheal tube through the vocal cords, and assistant anesthetist rotates the tube and passes beyond the cord under vision of main anesthetist, and by left hand, the assistant anesthetist also can feel the tactile sensation of tracheal tube passing through the larynx into the trachea [Figure 1d–f]. This maneuver can help the anesthetist in passing the tracheal tube without any difficulty.

Figure 1

(a) (During videolaryngoscopy) showing impingement of tracheal tube at right arytenoid, (b) showing 90° counterclockwise rotation of tube and it passes into laryngeal inlet, (c) showing passing of tracheal tube into the trachea. (d) (During direct laryngoscopy and as seen by main anesthetist doing laryngoscopy) showing impingement of tracheal tube at the laryngeal inlet, (e) showing 90° counterclockwise rotation of tube and it passes into the laryngeal inlet, and (f) showing passing of tracheal tube into the trachea

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