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Year : 2017  |  Volume : 11  |  Issue : 4  |  Page : 512

“Two-hand-manoeuver” during nasotracheal intubation

Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Mumbai, Maharashtra, India

Correspondence Address:
Sohan Lal Solanki
Department of Anaesthesiology, Critical Care and Pain, 2nd Floor, Main Building, Tata Memorial Centre, Mumbai - 400 012, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sja.SJA_229_17

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Date of Web Publication22-Sep-2017

How to cite this article:
Solanki SL, Kaur J. “Two-hand-manoeuver” during nasotracheal intubation. Saudi J Anaesth 2017;11:512

How to cite this URL:
Solanki SL, Kaur J. “Two-hand-manoeuver” during nasotracheal intubation. Saudi J Anaesth [serial online] 2017 [cited 2022 May 23];11:512. Available from:


Nasotracheal intubation is the mainstay of airway management in oral and facial surgeries. Normally, nasotracheal intubation can be done with no or little difficulties, but sometimes, there may be some difficulty in passing tracheal tube through the nasal passage or passing beyond the epiglottis into the trachea.

After passing through the nasal cavity, tracheal tube may impinge on laryngeal structures.[1] Induction of general anesthesia may approximate the soft palate; tongue and epiglottis to the posterior pharyngeal wall and tracheal tube mostly impinge on epiglottis, right arytenoid, or interarytenoid.[2] During flexible fibreoptic intubation when tracheal tube impinge on this structure, it was shown that a 90° counterclockwise rotation of tube usually helps in the smooth advancement of the tracheal tube into the trachea.[2]

For a normal nasotracheal intubation, having problem of tracheal tube impingement at epiglottis, right arytenoids, interarytenoid, or other laryngeal structures, we here propose a simple maneuver (“Solanki-two-hand maneuver”) where an assistant anesthetist holds the larynx or can give backward, upward, and rightward pressure with left hand and rotates the tracheal tube 90° counterclockwise with the right hand and advances tracheal tube into the trachea under vision of a videolaryngoscopy performed by main anesthetist [Figure 1]a,[Figure 1]b,[Figure 1]c; or if direct laryngoscopy by a Macintosh laryngoscope is performed, the main anesthetist performing direct laryngoscopy can see the tracheal tube impingement and subsequent passing the tracheal tube through the vocal cords, and assistant anesthetist rotates the tube and passes beyond the cord under vision of main anesthetist, and by left hand, the assistant anesthetist also can feel the tactile sensation of tracheal tube passing through the larynx into the trachea [Figure 1]d,[Figure 1]e,[Figure 1]f. This maneuver can help the anesthetist in passing the tracheal tube without any difficulty.
Figure 1: (a) (During videolaryngoscopy) showing impingement of tracheal tube at right arytenoid, (b) showing 90° counterclockwise rotation of tube and it passes into laryngeal inlet, (c) showing passing of tracheal tube into the trachea. (d) (During direct laryngoscopy and as seen by main anesthetist doing laryngoscopy) showing impingement of tracheal tube at the laryngeal inlet, (e) showing 90° counterclockwise rotation of tube and it passes into the laryngeal inlet, and (f) showing passing of tracheal tube into the trachea

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kristensen MS. The Parker Flex-Tip tube versus a standard tube for fiberoptic orotracheal intubation: A randomized double-blind study. Anesthesiology 2003;98:354-8.  Back to cited text no. 1
Asai T, Shingu K. Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: Incidence, causes and solutions. Br J Anaesth 2004;92:870-81.  Back to cited text no. 2


  [Figure 1]


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