Letters to Editor

LETTER TO EDITOR – A modified technique for difficult nasogastric tube insertion

Ghanshyam Yadav*, Saurabh K Das**, Gaurav Jain***, Sujali Choupoo**

*Assistant Professor, **Resident

Department of Anaesthesiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP, India, 221005.

***Assistant Professor, Department of Anaesthesiology, Teerthankar Mahaveer Medical College Muradabad, UP, India.

Nasogastric tube placement is usually performed by the conventional blind method. However, the routine technique might fail in several situations e.g. pharyngeal growths, post-radiation fibrosis and patients under general anesthesia etc. The failure rates have been reported to be as high as 50% in the first attempt with the head in neutral position.1-4 Various modifications to the standard technique have been described in the literature to prevent the tube impaction; thereby, improving the success rate of this technique. We describe here a modification in the traditional method, utilizing the fibreoptic bronchoscope and endotracheal tube, used successfully in a patient with carcinoma buccal mucosa, after multiple failed attempts by conventional blind method.

A 65 year old male diagnosed as carcinoma buccal mucosa (stage 4), presented to the oncology department with chief complaints of progressive restriction in mouth opening and difficulty in feeds. On examination, temporo-mandibular joint ankylosis and tissue fibrosis was suspected as the possible cause, considering the radiotherapy cycles, he received for the past 6 months. After multiple failed attempts, patient was referred to anaesthesia department for further intervention. After written and informed consent, patient was pre-medicated with glycopyrrolate (0.2 mg I.M.), while sedative/analgesics were omitted. In the operating room, the patient was placed supine with the head in neutral position. Oxymetazoline 0.05%, 3 ml and lidocaine jelly 2% were instilled into the right nostril. Supplemental oxygen was delivered through the other nostril.  FOB was lubricated and loaded with an ETT, introduced through the right nostril and advanced towards the oesophagus. Bronchoscopy revealed distorted anatomy of hypopharynx secondary to post-radiation fibrosis. Bronchoscope was introduced into the oesophagus and ET tube was railroaded over the scope into the oesophagus. The bronchoscope was removed and ETT placement into oesophagus confirmed by capnography. An NG tube was easily inserted through the lumen of ET tube, and advanced into the oesophagus and confirmed by aspirating gastric content, insufflating air and auscultating bubbling sound over the epigastrium. ETT was split along its length and taken out to allow the large NG tube adapter. We found this technique very easy and atraumatic for the patients.


  1. Wolf TR, Fosnocht DE, Linscott MS. Atomized lidocaine as topical anaesthesia for nasogastric tube placement: a randomized double blind, placebo-controlled trial. Ann Emerg Med 2000;35:421-5. [PubMed]
  2. Fakhari S, Bilehjani E, Negargar S, Mirinazhad M, Azarfarin R.  Split Endotracheal Tube as a Guide Tube for Gastric Tube Insertion in Anesthetized Patients: A Randomized Clinical Trial. J Cardiovasc Thorac Res 2009;1:17-22. [Online]
  3. Appukutty J, Shroff PP.  Nasogastric tube insertion using different techniques in anesthetized patients: a prospective, randomized study. Anesth & Analg 2009;109:832–5. [PubMed] doi: 10.1213/ane.0b013e3181af5e1f.
  4. Kureghian JD, Kumar S, Jani P. Nasogastric tube insertion in difficult cases with the aid of a flexible nasendoscope. J Laryngol Otol. 2011 Sep;125(9):962-4. doi: 10.1017/S0022215111000946. Epub 2011 May 31. [PubMed]