Use of esophageal stethoscope as an introducer during nasotracheal intubation.

To the Editor:—We read with interest the case report by Williams et al. of an accidental middle turbinectomy during nasotracheal intubation. Though the authors stated it as being the first case, there have been some earlier reports on middle turbinectomy. Prewarming of endotracheal tube (ETT) to soften, lubricating of the ETT, and using a vasoconstrictor have been recommended to reduce trauma during nasotracheal intubation. Nonetheless, severe nasal traumas have been reported. Others have described a technique to facilitate the atraumatic passage of nasotracheal tubes, such as an intraluminal balloon. However, this is not widely available. An alternative that might be useful is the esophageal stethoscope–ETT combination, which can be assembled at bedside by using readily available anesthetic materials. In addition, the esophageal stethoscope can be used alone after it used as a guide. A pediatric esophageal stethoscope (17 French: Mallinckrodt Medical, Athlone, Ireland) is positioned with its tip protruding about 2 cm out of the distal end of an ETT (internal diameter: 7.0 mm Mallinckrodt Medical). The proximal tip of esophageal stethoscope is connected to a syringe via a 3-way stopcock. Injecting about 6 ml of air and locking the 3-way stopcock keeps the distal portion of esophageal stethoscope inflated to the same diameter of the ETT (fig. 1). If nasal trauma occurs during the advancement of ETT, this method would be effective in preventing the introduction of a torn part of nasal tissue into the trachea or the obstruction of ETT by it, because the end of ETT is obturated with esophageal stethoscope. For fiberscopeguided intubation, this method may prevent visual obstruction from mucus plug or bleeding. During direct laryngoscopy, its distal tip provides a portion to grasp with intubating forceps, preventing ETT cuff damage. When the esophageal stethoscope is inflated, the tip has a tendency to bend to the bevel side, which seems to be the drawback of this method. However, you can take advantage of the bent tip and direct the ETT away from the tubinates, which can avoid the possibility of turbinate trauma.