Intraoperative conversion of nasal to oral intubation in a skull base surgery

Introduction: The traditional method of nasal to oral tracheal tube change is simply removing the nasoendotracheal tube and replacing it with an oro- endotracheal tube via direct laryngoscopy. We had encountered one such scenario where in there was a need for change of nasal ET to oral route during a skull base surgery. Case Summary: A 30 yr male presented with history of double vision and headache since 3 months with normal neurological exam. His MRI showed a large well defined lobulated extraxial mass noted in the spheno-clival region measuring 6.7 x 4.8x 3.0 cms, extending in to sphenoid sinus. A midfacial approach was planned with the plastic surgeon exposing the maxilla by lefort 2 incision, followed by transsphenoidal approach to the tumour by neurosurgeon. After consensus, nasal intubation was done to suite the midfacial approach but after the exposure neurosurgeon felt that it was suboptimal to resect the tumour by this aaproach. Hence transnasal transsphenoidal approach was thought to be a better option for optimal resection by surgeon. Hence he wanted a switch over the nasal endotracheal tube to the oral route. The patient was oxygenated with 100% O₂ for 5 minutes, throat pack was removed with the help of rigid endoscope and the initial assessment was done with the fiberoptic scope orally to see whether the glottic area is accessible. After confirming the accessibility ventilating bougie was inserted through the nasal endotracheal tube. Under the vision of FOB nasal ETT was withdrawn over the bougie till oropharynx. Then FOB was advanced in to trachea and another ETT was inserted over FOB orally and positon was visually confirmed. Nasal ETT and bougie were removed in total. Conclusion: In an unanticipated case this is the safer option because at any point of time if there was a problem then the nasal tube would have been reinserted on top of the bougie and also we were able to do the procedure without removing the pins and drapes.