A Secure Method of Nasotracheal Tube Fixation Using an
Infant Feeding Tube
V. Ravindra Bhat, MD, DA, DNB(Anesth), and G. Venkateshwaran, DA
Department of Plastic Surgery, Hand Surgery and Reconstructive Microsurgery, Ganga Hospital, Coimbatore, India
A well secured endotracheal tube is very essential for
the safe conduct of anesthesia. In maxillofacial surger-
ies, providing secure fixation of the nasotracheal tube
has always been a problem. We have used an infant
feeding tube that goes around the nasal septum for the
fixation of the nasal endotracheal tube. This method of
securing the nasotracheal tube does not hinder the sur-
gical access, is well tolerated by patients, and is safe.
(Anesth Analg 2004;99:1352–4)
cheal tube is used to secure the airway. When the
surgical field is away from the head and neck this can
easily be achieved. In maxillofacial surgeries, anesthe-
siologists have to provide the operating team with
maximum range of motion near the head of the patient
without jeopardizing the security of the endotracheal
tube. In surgeries requiring intraoperative assessment
of proper mouth occlusion or performing intermaxil-
lary fixation, nasotracheal intubation is preferable to
oral intubation. Various methods of fixation of the
nasotracheal tube have been described (1–3). We have
described a technique of fixing the nasotracheal tube
using an infant feeding tube (4).
ixation of the endotracheal tube is of vital impor-
tance in any general anesthetic procedure and in
the intensive care unit (ICU) where an endotra-
After obtaining permission from the IRB and informed
consent from the patients, seven patients with max-
illofacial injuries were included for the study of this
method of fixation of the nasotracheal tube. We
used polyvinylchloride tubes for nasotracheal intu-
bation in 3 patients and North Pole preformed RAE
tubes for 4 patients (7 mm for female patients and
8 mm for male patients). While performing nasotra-
cheal intubation the gloved little finger of the anes-
thesiologist was lubricated with 2% lidocaine jelly
and introduced gently into the nostril selected for
passing the nasotracheal tube. This cleared the nasal
passage of any debris, provided lubrication, and
provided the anesthesiologist with information re-
garding any deviation of the nasal septum. The
nasotracheal tube was put in warm water to soften
it so as to minimize the trauma to the nasal mucosa
during insertion. This tube was passed through the
nostril, and when the tube was in the oropharynx it
was examined for any debris occluding the lumen of
the endotracheal tube. The nasotracheal tube was
then guided into the larynx under direct laryngo-
scopic guidance using a Magill’s intubating forceps.
After confirming the position of the nasotracheal
tube it was secured in the following way.
• A 6 F infant feeding tube was passed through the
same nostril as the endotracheal tube and taken
out through the mouth (Fig. 1).
• A 10F suction cannula was passed through the
opposite nostril and brought out through the
mouth with a Magill’s forceps (Fig. 2).
• The infant feeding tube was threaded into the
suction cannula (Fig. 3).
• The suction cannula along with the infant feeding
tube was pulled out through the nostril. The in-
fant feeding tube was then encircling the nasal
septum (Fig. 4).
• A loose knot was tied in front of the columella
(Fig. 5). Care was taken that the knot was not
tight, which could have caused damage to the
Accepted for publication May 18, 2004.
Address correspondence and reprint requests to V. Ravindra Bhat
MD, DA, DNB(Anesth), Department of Plastic Surgery, Hand Sur-
gery and Reconstructive Microsurgery, Ganga Hospital, Swarnam-
bika Layout, Ramnagar, Coimbatore, India 641 009. Address email
©2004 by the International Anesthesia Research Society
Anesth Analg 2004;99:1352–4 0003-2999/04
• The two ends of the infant tube were used to
secure the nasotracheal tube (Fig. 6).
The oropharynx was examined for any bleeding.
The nasal endotracheal tube was observed intraoper-
atively to look for any accidental extubation or ad-
vancement into the trachea. At the end of the proce-
dure, in patients in whom extubation was planned on
the operating table, the infant feeding tube was cut
away from the knot so that when the endotracheal
tube was removed the knot would come along with
the tube. After extubation the nasal mucosa, the ala of
the nose, and columella were observed for any pres-
sure necrosis or ulcerations. All patients were asked to
report any discomfort in the nose in the postoperative
period. Four patients were electively ventilated in the
postoperative ICU from 4 to 24 h. These patients re-
ceived IV infusion of propofol with a syringe pump
Figure 2. A 12F suction tube has been passed through the opposite
nostril and brought out through the mouth.
Figure 3. The infant feeding tube is being threaded into the suction
Figure 4. The suction tube has been pulled out of the nostril. The
infant feeding tube has come out through the opposite nostril along
with the suction tube.
Figure 5. A loose knot is tied in front of the columella using the two
ends of the feeding tube.
Figure 1. A 6F infant feeding tube has been passed through the same
nostril as the endotracheal tube and has been brought out through
and intermittent IV injection of fentanyl 2 micrograms
per kg body weight every second hour. They did not
receive any muscle relaxants.
No significant bleeding was observed from either nos-
tril after securing the nasotracheal tube. There was
minimal movement of the nasotracheal tube intraop-
eratively. None of the patients had any injury to the
nasal mucosa, ala of the nose, or the columella. In the
4 patients in whom elective postoperative ventilation
was chosen, the patients accepted the nasotracheal
tube comfortably. None of the patients complained of
any discomfort in the nose.
Endotracheal tubes have to be secured effectively dur-
ing surgery. Inadvertent extubation during surgery
can be life-threatening. Movement of the endotracheal
tube up and down can cause trauma to the laryngeal
and tracheal mucosa. At the same time, techniques
used to secure the tube should not interfere with the
Many methods have been advocated to secure the
nasotracheal tube. Adhesive tapes have been used
alone and along with adhesives such as tincture ben-
zoin on the tube and skin. Sutures taken through the
nasal septum have been used to secure the nasotra-
cheal tube (2). Umbilical tapes or discarded oxygen
tubing have been used. A method using the RAE tube
and use of the Mayo table to secure the endotracheal
tube has been described (3). All these techniques have
disadvantages, such as dislodgement of the tapes as a
result of constant movement during the surgery, the
development of allergy to the adhesive tapes, and
injury to the nasal septum as a result of the sutures
cutting through it. We have found that the technique
using an infant feeding tube to be very secure during
surgical manipulation. We have not encountered any
problems such as inadvertent extubation, septal dam-
age, or pressure necrosis. Most major maxillofacial
reconstructions are electively ventilated postopera-
tively, and we have found that patients tolerate this
technique of fixation well in the postoperative period
in the postanesthesia care unit.
We have used this technique only for those patients
who had maxillofacial surgeries and not in the ICUs as
a routine. The safety of this method of fixation needs
to be assessed in patients who need prolonged naso-
tracheal intubation. Popovich et al. (5) have safely
used this nasal bridle for periods of more than 30 days
in the ICU in critically ill patients for securing naso-
We have found this technique of fixation of the naso-
tracheal tube to be a very effective manner of stabili-
zation of the nasal endotracheal tube with the least
morbidity in the perioperative period. It rarely inter-
feres with the surgical field and is well tolerated by the
patient. The safety of this method for routine use in
the ICU needs to be evaluated.
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Figure 6. The nasotracheal tube is secured by the infant feeding tube
with a reef knot.
BRIEF REPORTANESTH ANALG