T1113 LARYNGOSCOI’E 90 :1980
`
`“HOW I DO IT"—HEAD AND NECK
`
`A Targeted Problem and Its Solution
`
`SECURING OF INTERMEDIATE DURATION FEEDING TUBES.*
`
`W. FREDERICK MCGUIRT, MD,
`and
`
`JOHN J. STROUT, M.D.,
`
`Winston—Salem, NC.
`
`INTRODUCTION.
`
`It is well recognized that nutritional support and a positive nitrogen bal-
`ance are essential to wound healing and the rebuilding of tissue. In the pre—
`operative and postoperative management of many patients with head and
`neck cancer, nasogastric feedings are necessary for several weeks to ensure
`that nutrition is adequate. The indwelling nasogastric tube remains the pre-
`ferable method for short to intermediate duration feeding (3—21 days) in
`the patient with an intact gastrointestinal tract. Cervical cutaneoesophageal
`feeding tubes may be appropriate for longer-term care, but are not usually
`necessary for the postoperative head and neck cancer patient and may, in
`fact, result in formation of a permanent cutaneoesophageal fistula after
`they are removed.
`
`The major drawback to an indwelling nasogastric feeding tube has been
`its premature, accidental removal. To replace this tube into or through a
`fresh operative field is risky, and one does not do it without reservation due
`to the possibility of traumatizing the suture line with possible subsequent
`infection, wound breakdown, or fistulization. Routine taping and pinning
`of the tube or including the tube within encircling dressings has not pre-
`vented patients from deliberately and nursing assistants from accidentally
`removing the tube. Actual suturing of the tube through the nasal columnella
`has been done, but the chronic pull on the columella and the constant nasal
`secretions may cause local infection and significant damage to the soft tis-
`sue and cartilage of the columella. In fact, we have seen two cases where the
`securing suture, constantly tugging in an irritated area, sawed the columella
`in two.
`
`To prevent those problems, we use the following method of securing naso-
`gastric tubes postoperatively in patients with head and neck cancer and in
`all patients who tend to dislodge their feeding tubes repeatedly. We have
`used this method in over 100 patients and in none has there been a prema-
`ture extubation or a complication.
`
`THE TECHNIQUE.
`
`The nares are first decongested with a topical spray. For the awake pa-
`
`tient, we prefer 5% cocaine solution, which both decongests and anesthe-
`wFrom the Section on Otolaryngology of the Department of Surgery, Bowman Gray School of
`Medicine of Wake Forest University, Winston-Salem, NC.
`Send Reprint Requests to W. Fred McGuh‘t, M.D., Section on Otoluryngology, Bowman Gray
`School of Medicine. Winston-Salem. NC 27103.
`
`2046
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`CORPAK Ex 1005, Page 1
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`MG GUIRT & STROUT: SECURING FEEDING TUBES.
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`2047
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`.. ell--
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`M\‘\\uiu’;77/w//l,,,,
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`l-B. Nuso-
`Flg. 1-A. anogastrlc tube with umbilical tnpo attached is removed retrogl'udely.
`gastric tube is passed through other nm-ls and brought out the mouth. 1-C. Umbilical tape is tied
`to the tip of tube and tube ls removed retrogradely (1-D). 1-13. Tune is tied around columellu.
`with square knot. l-F. Nusogastrlc tube is secured with second square knot.
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`CORPAK Ex 1005, Page 2
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`2048
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`MC GUIRT & STROUT: SECURING FEEDING TUBES.
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`tizes. The more widely patent naris is the one selected for passage of the
`tube. Initially, a small red rubber catheter is passed through one naris. The
`tip of the catheter is grasped in the oropharynx and brought outside the
`mouth so that a (SO-cm length of one-quarter-inch umbilical tape can be tied
`to it. The catheter is then removed retrogradely (Fig. l-A), a maneuver that
`leaves the tape in the naris. The tape is untied and the catheter is passed
`through the other naris so that its tip can again be grasped and brought
`outside the mouth (Fig. 1-B). The oropharyngeal end of the tape is tied to
`the tip of the catheter, and the catheter is again removed retrogradely (Fig.
`1-C) . In that manner, a loop of umbilical tape has been brought to lie around
`the nasal septum with a free end hanging externally from each naris (Fig.
`1—D). The umbilical tape is then tied loosely in a square knot over the colum-
`ella (Fig. 1-E), with approximately 5 mm. of slack left in the tape around
`the nasal septum. In a conventional manner, the nasogastric tube is then
`passed into the stomach through the pre—selected naris. A small amount of
`benzoin is painted 011 the tube where it enters the nose, and over that a
`small piece of one-half—inch cloth tape is placed. The ends of the umbilical
`tape are then tied securely in a square knot over the cloth tape to secure the
`izasogastgic tube against the previously-tied square knot over the columella
`Fig. 1-F .
`This tube cannot be removed unless the umbilical tape is cut. The slight
`degree of slack in the encircling umbilical tape, the width of that tape, and
`the fact that the pressure point on the posterior nasal septum lies over bone,
`all tend to prevent tissue erosion. The small amount of slack or “give” in
`the system also allows a change in pressure to be transmitted to the pos-
`terior septum when the tube is tugged down. That change in sensation rein-
`forces to the patient the idea that the tube is not to be removed.
`
`In summary, a method to secure a nasogastiic tube fo1 inteimediate-dur-
`ation tube feeding1s presented. Itis especially appropiiate during the post-
`operative care of a patient with head and neck cancer, when 1einse1tion of
`the tube carries the risk of rupture of a suture line. To date, in over 100
`patients, we have seen no complications and no premature extubations re-
`sulting from the use of this technique.
`
`THE NATIONAL SYMPOSIUM ON HAIR
`REPLACEMENT SURGERY.
`
`The National Symposium on Hai1 Replacement Su1ge1y — co-spons01ed
`by the American Academy of Facial Plastic and Reconstiuctive Surgery
`and The American Society for Dermatologic Su1ge1y will meet on Feb-
`ruary 6-8, 1981 at Ramada Inn, Beverly Hills, Los Angeles, California.
`
`This seminar will be an intensive practical course including lectures,
`panel d1scuss1ons, workshops and Videotapes covering all aspects of hair re-
`placement for the begmner and experlenced surgeon.
`
`For additional information contact: Richard Fleming, M.D., or Toby
`Mayer, M.D., Course Directors, at 9730 Wilshire Blvd, Ste. 216, Beverly
`Hills, CA 90212.
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