Effect of Nasotracheal Tube Bevel Orientation on Epistaxis, Intubation Difficulty, and Intraoperative Complications
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Abstract
Background: Nasal bleeding is a common event during nasotracheal intubation. The present trial examined whether altering bevel orientation (upward, downward, right, or left) affects the likelihood of epistaxis, ease of intubation, and intraoperative outcomes.
Methods: In this triple-blind randomized controlled trial, 200 candidates for elective oral and maxillofacial procedures were randomized into four groups based on bevel orientation. The principal endpoint was the frequency and severity of epistaxis. Secondary endpoints included intubation time, difficulty score, hemodynamic responses, and oxygen saturation. Data were evaluated using chi-square, ANOVA, and Kruskal–Wallis tests (p<0.05).
Results: The incidence and grading of epistaxis, intubation time, and difficulty did not significantly differ between the four orientations. Hemodynamic and oxygenation parameters remained stable throughout. Lateral orientations showed a non-significant tendency toward less bleeding and smoother tube passage.
Conclusion: Bevel direction did not significantly influence bleeding or difficulty of nasotracheal intubation, although subtle clinical advantages were observed. Larger trials are needed to clarify the potential benefits.
[1] Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth. 2012;109 Suppl 1:i68-i85.
[2] Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: results of the 4th National Audit Project. Br J Anaesth. 2011;106(5):617–631
[3] Aziz MF, Dillman D, Fu R, Brambrink AM. Comparative effectiveness of the C-MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Anesthesiology. 2012;116(3):629-636.
[4] Lewis SR, Butler AR, Parker J, Cook TM, Schofield-Robinson OJ, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review. Br J Anaesth. 2017;119(3):369-383.
[5] Heidegger T, Asai T. Fibreoptic intubation: a commitment to an indispensable technique. Br J Anaesth. 2023;131(5):793-796.
[6] X. Iijima T. Tips for naso-tracheal intubation: a clinical practice review. J Oral Maxillofac Anesth. 2025;4:13.
[7] Kim EM, Chung MH, Lee MH, Choi EM, Jun IJ, Yun TH, et al. Is Tube Thermosoftening Helpful for Videolaryngoscope-Guided Nasotracheal Intubation?: A Randomized Controlled Trial. Anesth Analg. 2019; 129(3):812-8.
[8] Won D, Kim H, Chang JE, Lee JM, Min SW, Jung J, et al. Effect of bevel direction on the tracheal tube pathway during nasotracheal intubation: A randomised trial. Eur J Anaesthesiol. 2021; 38(2):157-63.
[9] Park JY, Yu J, Kim CS, Mun T, Jeong WS, Choi JW, et al. Reverse tube direction and epistaxis in left nasotracheal intubation: a randomized controlled trial. Korean J Anesthesiol. 2024; 77(6):596-604.
[10] Sugiyama K, Manabe Y, Kohjitani A. A styletted tracheal tube with a posterior-facing bevel reduces epistaxis during nasal intubation: a randomized trial. Can J Anaesth. 2014; 61(5):417-22.
[11] Kim YC, Lee SH, Noh GJ, Cho SY, Yeom JH, Shin WJ, et al. Thermosoftening treatment of the nasotracheal tube before intubation can reduce epistaxis and nasal damage. Anesth Analg. 2000; 91(3):698-701.
[12] Prashant HT, Kerai S, Saxena KN, Wadhwa B, Gaba P. Comparison of cuff inflation method with curvature control modification in thermosoftened endotracheal tubes during nasotracheal intubation - A prospective randomised controlled study. Indian J Anaesth. 2021; 65(5):369-76.
[13] Özkan ASM, Akbas S, Toy E, Durmus M. North Polar Tube Reduces the Risk of Epistaxis during Nasotracheal Intubation: A prospective, Randomized Clinical Trial. Curr Ther Res Clin Exp. 2018; 90:21-6.
[14] Tan YL, Wu ZH, Zhao BJ, Ni YH, Dong YC. For nasotracheal intubation, which nostril results in less epistaxis: right or left?: A systematic review and meta-analysis. Eur J Anaesthesiol. 2021; 38(11):1180-6.
[15] Tong JL, Tung A. A Randomized Trial Comparing the Effect of Fiberoptic Selection and Guidance Versus Random Selection, Blind Insertion, and Direct Laryngoscopy, on the Incidence and Severity of Epistaxis After Nasotracheal Intubation. Anesth Analg. 2018; 127(2):485-9.
[16] Lewis SR, Butler AR, Parker J, Cook TM, Schofield-Robinson OJ, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review. Br J Anaesth. 2017; 119(3):369-83.
[17] Aziz MF, Dillman D, Fu R, Brambrink AM. Comparative effectiveness of the C-MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Anesthesiology. 2012; 116(3):629-36.
[18] Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827-848.
[19] Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022; 136(1):31-81.
[20] Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth. 2012; 109 Suppl 1:i68-i85.
[21] Kim H, Kim JE, Yang WS, Hong SW, Jung H. Effects of bevel direction of endotracheal tube on the postoperative sore throat when performing fiberoptic-guided tracheal intubation: A randomized controlled trial. Medicine (Baltimore). 2022; 101(35):e30372.
[22] Choudhry DK, Brenn BR, Lutwin-Kawalec M, Sacks K, Nesargi S, He Z. Effect of $90^\circ$ counterclockwise rotation of the endotracheal tube on its advancement through the larynx during nasal fiberoptic intubation in children: a randomized and blinded study. Paediatr Anaesth. 2016; 26(4):378-83.
[2] Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: results of the 4th National Audit Project. Br J Anaesth. 2011;106(5):617–631
[3] Aziz MF, Dillman D, Fu R, Brambrink AM. Comparative effectiveness of the C-MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Anesthesiology. 2012;116(3):629-636.
[4] Lewis SR, Butler AR, Parker J, Cook TM, Schofield-Robinson OJ, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review. Br J Anaesth. 2017;119(3):369-383.
[5] Heidegger T, Asai T. Fibreoptic intubation: a commitment to an indispensable technique. Br J Anaesth. 2023;131(5):793-796.
[6] X. Iijima T. Tips for naso-tracheal intubation: a clinical practice review. J Oral Maxillofac Anesth. 2025;4:13.
[7] Kim EM, Chung MH, Lee MH, Choi EM, Jun IJ, Yun TH, et al. Is Tube Thermosoftening Helpful for Videolaryngoscope-Guided Nasotracheal Intubation?: A Randomized Controlled Trial. Anesth Analg. 2019; 129(3):812-8.
[8] Won D, Kim H, Chang JE, Lee JM, Min SW, Jung J, et al. Effect of bevel direction on the tracheal tube pathway during nasotracheal intubation: A randomised trial. Eur J Anaesthesiol. 2021; 38(2):157-63.
[9] Park JY, Yu J, Kim CS, Mun T, Jeong WS, Choi JW, et al. Reverse tube direction and epistaxis in left nasotracheal intubation: a randomized controlled trial. Korean J Anesthesiol. 2024; 77(6):596-604.
[10] Sugiyama K, Manabe Y, Kohjitani A. A styletted tracheal tube with a posterior-facing bevel reduces epistaxis during nasal intubation: a randomized trial. Can J Anaesth. 2014; 61(5):417-22.
[11] Kim YC, Lee SH, Noh GJ, Cho SY, Yeom JH, Shin WJ, et al. Thermosoftening treatment of the nasotracheal tube before intubation can reduce epistaxis and nasal damage. Anesth Analg. 2000; 91(3):698-701.
[12] Prashant HT, Kerai S, Saxena KN, Wadhwa B, Gaba P. Comparison of cuff inflation method with curvature control modification in thermosoftened endotracheal tubes during nasotracheal intubation - A prospective randomised controlled study. Indian J Anaesth. 2021; 65(5):369-76.
[13] Özkan ASM, Akbas S, Toy E, Durmus M. North Polar Tube Reduces the Risk of Epistaxis during Nasotracheal Intubation: A prospective, Randomized Clinical Trial. Curr Ther Res Clin Exp. 2018; 90:21-6.
[14] Tan YL, Wu ZH, Zhao BJ, Ni YH, Dong YC. For nasotracheal intubation, which nostril results in less epistaxis: right or left?: A systematic review and meta-analysis. Eur J Anaesthesiol. 2021; 38(11):1180-6.
[15] Tong JL, Tung A. A Randomized Trial Comparing the Effect of Fiberoptic Selection and Guidance Versus Random Selection, Blind Insertion, and Direct Laryngoscopy, on the Incidence and Severity of Epistaxis After Nasotracheal Intubation. Anesth Analg. 2018; 127(2):485-9.
[16] Lewis SR, Butler AR, Parker J, Cook TM, Schofield-Robinson OJ, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review. Br J Anaesth. 2017; 119(3):369-83.
[17] Aziz MF, Dillman D, Fu R, Brambrink AM. Comparative effectiveness of the C-MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Anesthesiology. 2012; 116(3):629-36.
[18] Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827-848.
[19] Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022; 136(1):31-81.
[20] Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth. 2012; 109 Suppl 1:i68-i85.
[21] Kim H, Kim JE, Yang WS, Hong SW, Jung H. Effects of bevel direction of endotracheal tube on the postoperative sore throat when performing fiberoptic-guided tracheal intubation: A randomized controlled trial. Medicine (Baltimore). 2022; 101(35):e30372.
[22] Choudhry DK, Brenn BR, Lutwin-Kawalec M, Sacks K, Nesargi S, He Z. Effect of $90^\circ$ counterclockwise rotation of the endotracheal tube on its advancement through the larynx during nasal fiberoptic intubation in children: a randomized and blinded study. Paediatr Anaesth. 2016; 26(4):378-83.
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| Nasotracheal intubation Epistaxis Bevel orientation Airway management Randomized trial | ||
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How to Cite
1.
Nazemroaya B, Honarmand A, Karamati MM, Nafari MM. Effect of Nasotracheal Tube Bevel Orientation on Epistaxis, Intubation Difficulty, and Intraoperative Complications. Arch Anesth & Crit Care. 2025;.
