Analysis of risk factors for nasal bleeding associated with nasal endotracheal intubation and evaluation of the role of cranial imaging in risk prediction

doi:10.19438/j.cjoms.2025.04.010

Abstract

Abstract: PURPOSE: To analyze the risk factors associated with nasal bleeding during nasal tracheal intubation and to explore the role of cranial imaging data in predicting the risk of nasal bleeding, in order to optimize nasal tracheal intubation strategies. METHODS: A total of 614 patients who underwent oral and maxillofacial surgery through nasotracheal intubation in Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine from June 2020 to December 2021 were selected. The patients were divided into a positive nasal bleeding group and a negative nasal bleeding group according to whether they had nasal bleeding. Preoperative baseline data, intubation-related information, and cranial imaging data were collected to analyze the risk factors for nasal bleeding and to explore the application value of cranial imaging in risk prediction. RESULTS: A total of 614 patients were included, with 113 in the positive nasal bleeding group and 501 in the negative group. Male patients had a higher risk of nasal bleeding than female patients, and increased age and body mass index also elevated the risk of nasal bleeding. Histories of radiotherapy and chemotherapy, as well as smoking and alcohol abuse, were significantly more prevalent in the positive nasal bleeding group compared to the negative group. The mean nasal tube insertion time and nasal intubation resistance were significantly higher in the positive nasal bleeding group. Cranial CT scans revealed a significant correlation between nasal septal deviation values and the occurrence of nasal bleeding, particularly the maximum septal deviation value in the coronal plane and the maximum deviation site in the cross-sectional plane. The prediction models based on the maximum deviation values in the cross-sectional and coronal planes showed areas under the curve of 0.704 and 0.742, respectively. CONCLUSIONS: Age, nasal intubation time, the maximum deviation value in coronal plane, radiotherapy and chemotherapy history, nasal intubation resistance, the maximum deviation of nasal septum in transverse section, and the maximum deviation of nasal septum in coronal plane are independent risk factors for nasal tracheal intubation related epistaxis. Cranial CT imaging parameters have application value in predicting the risk of nasal bleeding.

Key words: Oral and maxillofacial surgery, Nasal tracheal intubation, Nasal bleeding, Risk factors, Nasal septal deviation

CLC Number:

R782.05.4

Fan Hao, Zhu Yuhang, Zhou Ren, Wang Yuxing. Analysis of risk factors for nasal bleeding associated with nasal endotracheal intubation and evaluation of the role of cranial imaging in risk prediction[J]. China Journal of Oral and Maxillofacial Surgery, 2025, 23(4): 377-383.

References

[1] Park DH, Lee CA, Jeong CY, et al.Nasotracheal intubation for airway management during anesthesia[J]. Anesth Pain Med(Seoul), 2021, 16(3): 232-247.
[2] 曹爽, 康华, 陈洁. 纤维支气管镜引导对经鼻腔气管插管患者术后拔管时鼻出血的影响[J]. 中国口腔颌面外科杂志, 2023, 21(3): 253-257.
Cao S, Kang H, Chen J.Effect of fiberoptic bronchoscope guided nasotracheal intubation on epistaxis after trachea extubation[J]. China Journal of Oral and Maxillofacial Surgery, 2023, 21(3): 253-257.
[3] St Mont G, Biesler I, Pförtner R, et al.Easy and difficult nasal intubation-a randomised comparison of Macintosh vs Airtraq^® laryngoscopes[J]. Anaesthesia, 2012, 67(2): 132-138.
[4] Hall CE, Shutt LE.Nasotracheal intubation for head and neck surgery[J]. Anaesthesia, 2003, 58(3): 249-256.
[5] Chauhan V, Acharya G.Nasal intubation: a comprehensive review[J]. Indian J Crit Care Med, 2016, 20(11): 662-667.
[6] 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[J]. Anesth Analg, 2018, 127(2): 485-489.
[7] Spinella MK, Nathan H, Wilson T, et al.A reliable protocol for fiberoptic nasal intubation[J]. J Oral Maxillofac Surg, 2025, 83(2): 148-155.
[8] Piepho T, Thierbach A, Werner C.Nasotracheal intubation: look before you leap[J]. Br J Anaesth, 2005, 94(6): 859-860.
[9] Coe TR, Human M.The peri-operative complications of nasal intubation: a comparison of nostril side[J]. Anaesthesia, 2001, 56(5): 447-450.
[10] Gross JB, Hartigan ML, Schaffer DW.A suitable substitute for 4% cocaine before blind nasotracheal intubation: 3% lidocaine-0.25% phenylephrine nasal spray[J]. Anesth Analg, 1984, 63(10): 915-918.
[11] Holzapfel L.Nasal vs oral intubation[J]. Minerva Anestesiol, 2003, 69(5): 348-352.
[12] Kim YC, Lee SH, Noh GJ, et al.Thermosoftening treatment of the nasotracheal tube before intubation can reduce epistaxis and nasal damage[J]. Anesth Analg, 2000, 91(3): 698-701.
[13] Sugiyama K, Manabe Y, Kohjitani A.A styletted tracheal tube with a posterior-facing bevel reduces epistaxis during nasal intubation: a randomized trial[J]. Can J Anaesth, 2014, 61(5): 417-422.
[14] Won D, Kim H, Chang JE, et al.Effect of bevel direction on the tracheal tube pathway during nasotracheal intubation: a randomised trial[J]. Eur J Anaesthesiol, 2021, 38(2): 157-163.
[15] Arun F, Icoz D, Akti A, et al.Using cone-beam CT for appropriate nostril selection in nasotracheal intubation[J]. Dentomaxillofac Radiol, 2024, 53(7): 515-520.
[16] Yasli SO, Canpolat DG, Baydan E, et al.Effectiveness of computed tomography-guided nasotracheal intubation procedure on predicting tube advancement difficulty and preventing epistaxis: a prospective case-control study[J]. J Pak Med Assoc, 2023, 73(10): 1981-1986.
[17] Sengel N, Toprak ME, Selmi NH, et al.Using of panoramic and posteroanterior cephalometric radiographs to identify the optimal nasal passage for nasotracheal intubation[J]. Niger J Clin Pract, 2022, 25(5): 647-652.
[18] Chi SI, Park S, Joo LA, et al.Identifying the more suitable nostril for nasotracheal intubation using radiographs[J]. J Dent Anesth Pain Med, 2016, 16(2): 103-109.
[19] Sim WS, Chung IS, Chin JU, et al.Risk factors for epistaxis during nasotracheal intubation[J]. Anaesth Intensive Care, 30(4): 449-452.
[20] Mukamal KJ.The effects of smoking and drinking on cardiovascular disease and risk factors[J]. Alcohol Res Health, 2006, 29(3): 199-202.
[21] Priyanka K, Sudhir KM, Reddy VCS, et al. Impact of alcohol dependency on oral health - a cross-sectional comparative study[J]. J Clin Diagn Res, 2017, 11(6): ZC43-ZC46.
[22] Glastonbury CM, Parker EE, Hoang JK.The postradiation neck: evaluating response to treatment and recognizing complications[J]. AJR Ame J Roentgenol, 2010, 195(2): W164-W171.
[23] Zheng C, Yu L, Jiang Y.Radiation-induced rhinosinusitis: mechanism research and clinical progress review[J]. World J Otorhinolaryngol Head Neck Surg, 2024, 10(4): 324-332.
[24] Aitkenhead AR, Moppett IK, Rowbotham DJ, et al.Smith and aitkenhead's textbook of anaesthesia[M]. 6th Ed. New York: Churchill Livingstone, 2013.
[25] Miller RD, Jr MCP.Basics of anesthesia[J]. New York: Churchill Livingston, 2011.
[26] Ahmed-Nusrath A, Tong JL, Smith JE.Pathways through the nose for nasal intubation: a comparison of three endotracheal tubes[J]. Br J Anaesth, 2008, 100(2): 269-274.
[27] Smith JE, Reid AP.Asymptomatic intranasal abnormalities influencing the choice of nostril for nasotracheal intubation[J]. Br J Anaesth, 1999, 83(6): 882-886.
[28] Jang CW, Escher AR Jr, Bordoni B, et al.Spur-of-the-moment: an exacting nasal intubation[J]. Cureus, 2022, 14(4): e23922.
[29] Lim CW, Min SW, Kim CS, et al.The use of a nasogastric tube to facilitate nasotracheal intubation: a randomised controlled trial[J]. Anaesthesia, 2014, 69(6): 591-597.