NPA use in mid-face and/or basal skull fracture patients

Hello, and thank you for your MedicASK question. Yes, Nasopharyngeal Airways (NPAs) are contraindicated for patients with mid-face or suspected basal skull fractures. These conditions “risk cephalad NPA insertion and possible damage to brain structures” (Atanelov, Aina, Smith, & Rebstock, 2024).

In the absence of a CT scan the diagnosis of a basal skull fracture can only be presumed by the presence or absence of clinical features:

• Blood from the ears or nose:
• It must be appreciated that blood from the nose of patients with traumatic injuries is very common as is blood in the external ear (which has dripped into the ear rather than from within).
• Cerebrospinal fluid from the ears or nose:
• CSF is a clear fluid, and its identification is difficult, even in hospital. The simplest test is the halo sign.
• Bruising around the mastoid process (Battle’s Sign) or both eyes (Racoon Eyes).
• Common following trauma and is more likely to be associated with soft tissue injury than a basal skull fracture. Do note that the development of this bruising will take some time.

We would like to emphasize the proper sizing and placement of the NPA. Measure the NPA against the patients face by measuring the distance from the nostril to the tragus of the ear, holding the NPA in a neutral position and ensure not to straighten it. For placement, lift the nostrils to reveal the larger nasal airway and place the NPA posteriorly (not cephalad), parallel to the floor of the nasal cavity, with the bevel of the tip facing toward the nasal septum. Use gentle yet firm pressure to pass the airway through the nasal cavity under the inferior turbinate.

It is also important to ensure that your patient is placed in an optimal position for placement. Align the upper airway for optimal air passage, and NPA insertion, by placing the patient into a proper sniffing position. Proper sniffing position aligns the external auditory canal with the sternal notch. To achieve the sniffing position, folded towels or other materials may need to be placed under the head, neck, or shoulders, so that the neck is flexed on the body and the head is extended on the neck. Patients requiring c-spine control will not be able to be placed into this position due to the limitations to their neck mobility.

Please note that there are additional contraindications for NPA insertion that include:

• Known nasal airway blockages
• Nasal fractures
• Marked septal deviation
• Coagulopathy (risk of epistaxis)
• Obvious cerebrospinal fluid rhinorrhea
• Known basilar skull fractures

Although there are two case reports of intracranial NPA placement in patients with basilar skull fractures, such extreme complications are rare and can only occur with devastating disruption of the basal skull, improper insertion technique (angling the NPA cephalad in the naris, instead of following the floor of the naris), or both. More common potential hazards of using the NPA include:

• Using an airway that is too long: this may cause the tip to enter the esophagus, increasing gastric distention and decreasing ventilation during rescue efforts.
• Injury to the nasal mucosa causing bleeding: this occurs in 30 percent of insertions and can lead to aspiration of blood or clots. (Wittels, 2024)

In conclusion, if you are unsure if the patient has sustained a mid-face or basilar skull fracture, err on the side of caution, and utilize another airway.