Repeated end otracheal tube cuff rupture during nasal intubation in a patient with restricted mouth opening: a case report

Nasotracheal intubation is frequently required in oral and maxillofacial oncosurgery when trismus precludes conventional oral laryngoscopy. Although generally regarded as a safe route, the nasal cavity can harborunrecognized anatomical variants — most notably a bony nasal spur or septal deviation — capable of lacerating the endotracheal tube cuff during passage, leading to a persistent air leak and repeated failed intubation attempts. We report a 40-year-old male with carcinoma of the right buccal mucosa and a mouth opening of one fingerbreadth, posted for wide local excision with modified radical neck dissection and pectoralis major myocutaneous (PMMC) flap cover, who underwent awake retrograde nasotracheal intubation. Two consecutive endotracheal tubes developed cuff leaks during nasal passage on the left side. Imaging obtained for surgical staging subsequently revealed a left-sided bony nasal spur with contralateral turbinate hypertrophy. Following failure of a further attempt through the right nostril, the patient ultimately required tracheostomy. This case highlights nasal spur as an important and often occult cause of recurrent cuff rupture during nasal intubation, and underscores the value of proactively reviewing available imaging, or performing simple clinical screening of nasal patency, before committing to a nostril in patients requiring nasal airway access.