For nasotracheal intubation, which nostril results in less epistaxis: right or left?

Abstract

BACKGROUND Nasotracheal intubation is usually required in patients undergoing oromaxillofacial, otolaryngological or plastic surgery to prevent the airway encroaching into the operating field. Epistaxis is the most common complication, but which nostril is associated with a lower incidence and severity of epistaxis is still unclear. OBJECTIVE When both nostrils are patent, to determine the preferred nostril for nasotracheal intubation under general anaesthesia. DESIGN A systematic review and meta-analysis of randomised controlled trials (RCTs). The primary outcome was the incidence of epistaxis and the secondary outcomes included the incidence of severe epistaxis, the time required to pass the tube through the nasal passage and total intubation time. DATA SOURCES PubMed, Embase and the Cochrane Register of Controlled Trials were searched from database inception to 1 March 2020. ELIGIBILITY CRITERIA The only studies included were RCTs comparing epistaxis related to nasotracheal intubation via right or left nostril, in adult surgery patients undergoing general anaesthesia. RESULTS Ten RCTs with 1658 patients were included. Compared with the left nostril, intubation via the right nostril was associated with a significantly lower incidence of epistaxis: risk ratio (RR) and 95% confidence intervals (CI) were 0.78 (0.62 to 0.99), P = 0.04: a lower incidence of severe epistaxis (five studies, n=923), RR 0.40 (0.22 to 0.75), P = 0.004: and a shorter intubation time (three studies, n=345), mean difference −7.28 (−14.40 to −0.16) seconds, P = 0.05. In two studies (n=310), no significant difference between the right and left nostril was observed in the time to pass the tube through the nasal passages, mean difference −0.59 (−1.95 to 0.77) s, P = 0.40. CONCLUSION On the basis of the current available evidence, when both nostrils are patent, the right nostril is more appropriate for nasotracheal intubation, with a lower incidence and severity of epistaxis and faster intubation time. TRIAL REGISTRATION The study protocol has been registered in PROSPERO (CRD42020169949).

Spur-of-the-Moment: An Exacting Nasal Intubation

“…The finding of the spur deriving from the nasal septum is around 1.2% [ 10 ]. The nasal spur can cause pain, particularly rhinogenic contact point ear pain; the latter is an otalgic pain with tinnitus caused by contact between the spur and the intranasal mucosal [ 11 ]. Tendentially, in the presence of a bone spur, an endoscopic operation can be carried out.…”

“…The nasotracheal approach to intubation is never without risk or minor trauma. One of the most recurrent events is epistaxis, which is most noticeable if the procedure starts from the left nostril; the right nostril is less prone to epistaxis and demonstrates a faster access rate [ 11 ]. Intubation from the right nostril better respects the anatomy of the retropharyngeal wall when the tube is inserted [ 12 ].…”

Impact of choice of nostril on nasotracheal intubation when using video rigid stylet: a randomized clinical trial

“…Epistaxis that occurs with a video stylet can lead to a blood-stained lens, which can obscure the field of view and lead to failed intubation. In two systematic reviews, nasotracheal intubation via the left nostril significantly increased the risk of epistaxis than via the right nostril [ 5 , 6 ]. It has been thought that the tube bevel’s orientation can impact nasotracheal intubation.…”

“…Although there is no consensus about which nostril is better for nasotracheal intubation, several studies found that the right nostril may be more suitable for laryngoscopic nasotracheal intubation [ 2 – 4 ]. Two systematic reviews showed that intubation via the right nostril is associated with faster intubation and lower incidence of epistaxis [ 5 , 6 ].…”

Effectiveness of computed tomography-guided nasotracheal intubation procedure on predicting tube advancement difficulty and preventing epistaxis: a prospective case-control study

“…Epistaxis, which frequently appears with varying severity, is the most common complication of nasotracheal intubation. 2 Regarding predicting the tube advancement difficulty through the nasal passage, the general recommendation is to perform nasal endoscopy before intubation which is a time-consuming and equipment-requiring procedure. 3,4 The higher rate of success and the shorter operation time in surgeries have come to be achieved by the guidance of many radiological imaging devices, like ultrasonography (USG), magnetic resonance imaging (MRI), computed tomography (CT) imaging and others.…”