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Abstract
Patients having oral and maxillofacial operations often require nasal intubation, but limited mouth opening and unfavourable nasal anatomy
can make it difficult. We aimed to find out whether there is an association between the prediction of difficult nasal intubation on computed
tomography (CT) and actual problems. We retrospectively reviewed the imaging and anaesthetic records of 77 patients who had replacement
of the temporomandibular joint (TMJ) as these patients often have limited mouth opening and have had a preoperative CT. There was a
positive correlation between a radiographically-assessed difficult nostril and difficulty of intubation (p<0.001). The positive predictive value
was 71.4%. As a consequence, our radiologists now routinely report on the nasal cavity in these patients, and their report and the scan are
then reviewed by the anaesthetist before intubation. Our results suggest that review of the CT before planned nasal intubation should be part
of routine practice.
2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction
Nasal intubation of patients having oral and maxillofacial
operations can aid access and occlusal registration. It can also
enable intubation of those with restricted mouth opening, but
in these cases it can be more hazardous, and unfavourable
nasal anatomy can make it more challenging. These difficulties can be predicted using computed tomography (CT) or
3-dimensional CT models if they have been done.1 Patients
who have replacement of the temporomandibular joint (TMJ)
often have limited mouth opening and have had preoperative CT. We therefore reviewed their imaging and anaesthetic
Corresponding author at: Department of Oral and Maxillofacial Surgery,
QMC, Derby Road, Nottingham, NG7 2UH.
E-mail addresses: drdrgrimes@gmail.com (D. Grimes),
Iain.Macleod@nuh.nhs.uk (I. MacLeod), Timothy.Taylor@nuh.nhs.uk
(T. Taylor), Mary.OConnor@nuh.nhs.uk (M. OConnor),
andrew.sidebottom@nuh.nhs.uk (A. Sidebottom).
http://dx.doi.org/10.1016/j.bjoms.2015.09.034
0266-4356/ 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
D. Grimes et al. / British Journal of Oral and Maxillofacial Surgery 54 (2016) 8082
81
Table 1
Cases identified on computed tomography as being potentially difficult to
intubate (right nostril).
Sex
Side intubated
M
F
F
F
F
F
F
8
8.5
8
<8
<8
8
8.3
Left
Left
Right
Left
Right
Left
Left
Table 2
Intubation outcomes predicted on computed tomography (CT) compared
with actual outcomes.
Predicted on CT
the right nostril with the endotracheal tube in the right hand
and the laryngoscope in the left). Two senior radiologists
reviewed the scans independently to identify anatomy that
might impede nasal intubation. Any disagreement was
discussed until they achieved consensus.
We reformatted cross-curve (along the path of intubation)
images of the bone-window CT datasets, and identified the
point of minimum bony distance along the path of intubation.
We used standard PACS (picture archiving and communications system) mark-up tools to measure the maximum
circular cross-sectional area that could be accommodated
(Fig. 1). If the diameter of the circle was less than that of the
nasotracheal tube, that side of the nasal cavity was flagged
as potentially problematic. For safe nasal intubation, reinforced endotracheal tubes are used with an internal diameter
of 6.0 mm for women and 6.5 mm for men. Their external
diameters, 8.8 mm for women and 9.5 mm for men, were
those used for the CT measurements. The mucosa was not
considered to obstruct unless severely hypertrophied. CT
measurements were compared with the anaesthetic record
to establish whether a correlation existed. Data were collected and analysed using Microsoft Excel software. The
chi square test was done to test for a correlation between
the predicted difficulty on CT and the actual difficulty of
intubation.
Results
We reviewed the records and preoperative CT of 77 patients
(55 women, mean (range) age 43 (15 - 70) years). Fifty of
them satisfied the inclusion criteria. Records that did not state
which nostril had been intubated were excluded. Nasal intubation was identified as being potentially difficult in 12 cases
(8 women, mean (range) age 35 (18 - 57) years) because of
Easy
Difficult
Total
Actual intubation
Easy
Difficult
39
2
41
4
5
9
Total
43
7
50
the size of the nostril, but 2 of them were not included because
the record did not state which nostril had been used. The left
nostril was used in 9 of the 50 included. Seven patients had
potentially difficult right nostrils and a record of which side
was intubated (Table 1). In 4 of the 5 who were intubated on
the left, the reason given was that the right nostril was too
small.
The correlation between a radiographically difficult right
nostril and actual difficulty of intubation was significant
(p<0.001) (Table 2). When we repeated the test and included
all the excluded cases (intention to treat) with the assumption
that the right nostril was intubated successfully in them all,
the correlation was again significant (p<0.001). The negative
predictive value of CT for difficult intubation was 90.7%, the
positive predictive value was 71.4%.
Discussion
CT is recognised as a reliable technique for nasal
measurement,2,3 and our results show that assessment of the
scan is a useful adjunct to the anaesthetist when planning
nasal intubation. Whilst it does not eliminate the possibility of intubation being difficult, it substantially reduces it.
Our radiologists now routinely report on the nasal cavity in
this group of patients, and it requires only a small amount of
additional time (about 5 minutes). The anaesthetist bases the
choice of nostril on the information given.
Review of the CT before a planned difficult nasal intubation can potentially assist the anaesthetist considerably, and
should be part of routine practice.
Conict of Interest
We have no conflicts of interest.
82
D. Grimes et al. / British Journal of Oral and Maxillofacial Surgery 54 (2016) 8082
References
1. OConnor M, Sidebottom AJ. Is the 3-D CT model useful to our anaesthetists? Br J Oral Maxillofac Surg 2013;51:2623.
2. Dastidar P, Heinonen T, Numminen J, Rautiainen M, Laasonen E.
Semi-automatic segmentation of computed tomographic images in