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  Table of Contents 
Year : 2021  |  Volume : 22  |  Issue : 1  |  Page : 111-113

Nasotracheal intubation and the resulting ulcers: Learning points

1 Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Otorhinolaryngology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission23-Oct-2020
Date of Decision14-Dec-2020
Date of Acceptance14-Dec-2020
Date of Web Publication22-Feb-2021

Correspondence Address:
Dr. Bharat Paliwal
G-80, Parsvnath City, Jodhpur - 342 013, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/TheIAForum.TheIAForum_167_20

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How to cite this article:
Paliwal B, Roy S, Kaushal D, Kumari K, Bhatia P. Nasotracheal intubation and the resulting ulcers: Learning points. Indian Anaesth Forum 2021;22:111-3

How to cite this URL:
Paliwal B, Roy S, Kaushal D, Kumari K, Bhatia P. Nasotracheal intubation and the resulting ulcers: Learning points. Indian Anaesth Forum [serial online] 2021 [cited 2021 May 9];22:111-3. Available from: http://www.theiaforum.org/text.asp?2021/22/1/111/309830


Nasotracheal intubation is often required during maxillofacial, otorhinolaryngology, and onco-surgery procedures. Pressure ulcer at the ala of the nose is an unwanted complication of nasal intubation in these surgeries. These ulcers cause pain and cosmetic problems. We have also come across one such unfortunate incident. A 54-year-old diabetic and hypertensive American Society of Anesthesiologists class 2 male patient was posted for wide local excision with reconstruction using radial forearm-free flap and modified radical neck dissection for left buccal mucosa carcinoma (T4N0M0). After induction, the airway was secured with 7.5mm flexometallic tube. Endotracheal tube (ETT) traction from the weight of the breathing circuit was taken care using towel clips. Intraoperatively, hypotensive anesthesia was given and the surgery lasted for 12 h. After surgery, when the drape was removed, an ulcer on the ala of the nose and an ulcer on the bridge of the nose were noted [Figure 1]a. The surgeons were notified. Neosporin ointment was applied over the lesions. The ulcers healed over 3 weeks, leaving a dark punch-out spot [Figure 1]b and [Figure 1]c.
Figure 1: (a) Ulcer on the nasal ala and bridge of the nose – immediate postoperative period. (b) Ulcer appearance at 1 week postoperatively. (c) Healed ulcer at 3 weeks postoperatively

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The incidence of nasal ala ulcer following oral surgery is 2.2%–24.48%.[1] These are associated with both nasotracheal and nasogastric tubes. Risk factors include increased age,[1] male gender,[1] and prolonged surgery (>10 h),[2] all of which were present in our case. The proposed mechanism of nasal ala ulcer is abutting of the ETT to the nasal ala due to traction on the ETT by surgical drapes and unintentional pressure from the surgeon's arm resting on the ala of nose over the drapes. Ulcer on the bridge of the nose may have resulted from the pilot balloon of the ETT in contact with it under the drape. Impaired perfusion from deliberate hypotension induced for minimizing blood loss may be an additional predisposing factor.

Different tubes, connector and fixation methods have been tried to prevent this complication.[3],[4] Their use is limited either because they are bulky or hamper surgeon's field and hand movements. Few others have used a polyvinyl acetyl sponge pack to prevent alar necrosis[4] or inserted calcium sodium alginate or paraffin between the tube and the mucosa inside the nostril.[5] These packing materials sometimes cause excessive pressure inside the nostril and may in fact predispose to ulcers. Hydrocolloid dressing seems to be better solution for nasal packing as it is thinner, less costly than other methods, sticks easily to the alar skin, does not increase intra-nostril pressure, and does not hamper the surgical field.[5]

Because nasal ulcers still occur despite a flexible tube and managing circuit traction, we suggest, besides prophylactic use of hydrocolloid dressings and reducing the period of deliberate hypotension to <10 h, being vigilant of the nasotracheal tube position during surgical draping and manipulations, use of transparent drapes, and cautious reminder to the surgeons not to put the weight of their hands or elbows over the patient to minimize these complications.

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There are no conflicts of interest.

  References Top

NLM- Tsukamoto M, Kobayashi M, Yokoyama T. Risk Factors for Pressure Ulcers at the Ala of Nose in Oral Surgery. Anesth Prog. 2017; 64:104-5.  Back to cited text no. 1
Huang TT, Tseng CE, Lee TM, Yeh JY, Lai YY. Nasal ala pressure sore: Easily missed complication of nasotracheal tube intubation. J Med Sci 2002;22:101-4.  Back to cited text no. 2
Cherng CH, Chen YW. Using a modified nasotracheal tube to prevent nasal ala pressure sore during prolonged nasotracheal intubation. J Anesth 2010;24:959-61.  Back to cited text no. 3
Singh R, Sood N, Kerai S, Puri A. Use of Merocel® aids in prevention of nasal pressure ulcers following nasal intubation: Case series of 33 patients. Indian J Anaesth 2017;61:513-5.  Back to cited text no. 4
[PUBMED]  [Full text]  
Iwai T, Goto T, Maegawa J, Tohnai I. Use of a hydrocolloid dressing to prevent nasal pressure sores after nasotracheal intubation. Br J Oral Maxillofac Surg 2011;49:e65-6.  Back to cited text no. 5


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