Sohan L Solanki1, Jeson R Doctor1. 1. Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
To the Editor,We read with interest the article on “changing nasal endotracheal tube to opposite nostril in a patient with no mouth opening under general anesthesia, after initial awake fiberoptic intubation” by Barua, et al.[1] We wish to congratulate the authors for the successful management of an intraoperative problem requiring a change of nasal endotracheal tube from one nostril to the other nostril. Although the authors managed to change the endotracheal tube (ETT) successfully, we have few concerns over the management and the message being conveyed by this article.This case is an adult patient with carcinoma buccal mucosa involving the maxilla and part of the mandible and requiring wide excision of buccal mucosa, maxillectomy and segmental mandibulectomy, and most probably a reconstructive flap (which is not mentioned by authors). The same side of the nostril should not be used for nasal intubation if the plan of surgery involves a maxillectomy. So, it was the incorrect preoperative planning for airway management.This patient had nil mouth opening preoperatively. As per the surgical plan, with segmental mandibulectomy, maxillectomy, buccal mucosa wide excision, and reconstructive flap these patients mostly warrant an elective tracheostomy intraoperatively for postoperative airway patency. So, if the surgeons were unhappy with the ETT in their field, they could have easily done an early tracheostomy rather than changing the ETT from one nostril to the other.The authors passed an adult fiberoptic scope from the other nostril and then by the side of the ETT to enter the trachea. They succeeded but this can lead to a theoretical trauma to the vocal cord or membranous granuloma of the vocal cord[2] and/or prolonged hoarseness in postoperative period. In our view a proper preoperative planning of airway is required to avoid such unwanted intraoperative interventions. An airway plan should be discussed with surgeons at the time of the surgical safety checklist.