Anaesthesia, 1993, Volume 48, pages 575-580

The nasopharyngeal airway

Assessment of position by fibreoptic laryngoscopy

M. D. STONEHAM

Summary
Artijicial nasopharyngeal airway position and performance were assessed in I20 anaesthetised adult patients. Using a fibreoptic
laryngoscope mean distances from nares to larynx were measured at 209 mm ( S D 11) in males and 180 mm ( S D 11) in females;
those from nares to epiglottis were 159 mm ( S D 12) in males and 140 mm ( S D 11) in females. Nasopharyngeal airways were
frequently misplaced, 60% lying beyond the tip of the epiglottis and 13% lodged in the vallecula. Forty-two percent of subjects
had clinical evidence of respiratory obstruction. Nasopharyngeal airway compression in the nasopharynx and obstruction by the
tongue and soft palate were common causes of respiratory obstruction. Regression analysis revealed that nares-epiglottis length
correlated signijicanfly with subject height ( t = 3.9, p = 0.0002), but not with three external measurements made around the
head and neck. Head flexion and extension resulted in comparatively little relative movement of the nasopharyngeal airway.
Nasopharyngeal airway length and diameter should be standardised to optimise performance.

Key words
Equipment; airway, nasopharyngeal.

The nasopharyngeal airway is used to assist in the main-
tenance of a clear airway during anaesthesia, in the
recovery ward. or in an emergency. It may also be used
during induction of anaesthesia in circumstances when the
patient might not tolerate an oropharyngeal airway. The
nasopharyngeal airway has been used successfully in the
past to facilitate access to the trachea for suctioning and
fibreoptic bronchoscopy [I], and for nasogastric and naso-
tracheal intubation [2].
Early nasopharyngeal airways were plain, uncuffed red
rubber tubes but these have largely been replaced with latex
or polyvinyl chloride tubes. Displacement of the airway
into the nasopharynx is prevented by a flange on the
proximal end, and the Portex pack now includes a safety
pin as a further safeguard [3].
The ability of the nasopharyngeal airway to maintain
airway patency is critically dependent on (1) the internal
diameter of the airway when correctly positioned and
(2) the position of the distal end of the airway relative to
anatomical structures, particularly the epiglottis and
tongue. Movement of the airway relative to laryngeal struc-
tures during flexion or extension of the head and neck may
occur, however.
Portex nasopharyngeal airways have an internal
diameter of 6, 7, 8 or 9 mm, but the lumen may be
compressed, sometimes completely, by passage through the
nasopharynx. Ideally the length of the tube should be such
that, following full insertion up to the flange, the tip
protrudes beyond the pharyngeal edge of the soft palate
but does not extend past the epiglottis [4]. Nasopharyngeal
airways are available in a range of sizes but the suitability
of these has not been properly assessed. The length of
Portex airways increases as the internal diameter increases,
although this is not based on a British Standard specifi-
cation. There is, however, an American Standard which
specifies lengths which are 10 to 20 mm less than the Portex
airways [5].
The purposes of this study were to assess the patency and
position of Portex nasopharyngeal airways by fibreoptic
laryngoscopy and to investigate whether the airways are
available in appropriate lengths. In addition, the possibility
of a relationship between the length of nasopharyngeal
airway required and various external measurements of the
face and neck was examined. Lastly, an assessment was
made of the extent to which head and neck movements
altered the position of the distal tip of the nasopharyngeal
airway relative to laryngeal structures.
Methods
The study was approved by the Hospital Ethics committee.
Patients selected for study were men and women, aged

M.D. Stoneham, MA, MB, BChir, Registrar, Department of Anaesthesia, Royal Naval Hospital, Stonehouse, Plymouth
PLI 3JY.
This study was presented in part at the 1992 Winter Meeting of the Society of Anaesthetists of the South Western Region
and awarded the President’s prize.
Accepted 19 January 1993.

O003-2409/93/070575 +06 %OS.OO/O @ 1993 The Association of Anaesthetists of Gt Britain and Ireland 575
576 M . D . Stoneham
Vallecula
Epiglottis
Vocal cords
m,, \ \- \ ,\R\
\ \ - \
Fig. 1. Measurement of nares-larynx (NL) distance with
nasopharyngeal airway in siiu.
16-80 years, presenting for routine surgery under general
anaesthesia. Patients having emergency surgery or
requiring a rapid sequence induction or those with known
nasal abnormalities, vasomotor rhinitis or bleeding diath-
eses were not studied. Patients to be included in the third
part of the study were examined pre-operatively to ensure
that they had a full range of neck movements. Written
informed consent from each unpremedicated patient was
obtained before inclusion in the study. Age, sex, height and
weight of all patients were recorded.
Three additional measurements were made on each
subject in an attempt to relate required nasopharyngeal
airway length to various external measurements of the face
and neck: (1) distance from tip of nose to angle of man-
dible (NM); (2) distance from nose to tragus of the ear
(NT); (3) cjistance from thyroid prominence to tip of chin
with the neck fully extended-the thyro-mental distance
(TM).
Induction of anaesthesia was carried out in the ‘stan-
dard’ anaesthetic position with one or two pillows behind
the head and neck. After induction with thiopentone or
propofol, anaesthesia was maintained using 1-2% iso-
flurane or enflurane in 66% nitrous oxide in oxygen.
When a surgical plane of anaesthesia had been achieved,
a well-lubricated Portex nasopharyngeal airway with
attached safety pin through the flange was inserted into the
most suitable nostril as assessed by the ‘sniff test pre-
operatively. Men and women patients initially received
8 mm or 7 mm airways respectively. No topical vasocon-
strictor was used. If gentle insertion was unsuccessful,
insertion in the other side was attempted. If this was
unsuccessful, a smaller size was inserted. Insertion of the
airways was performed by the same anaesthetist (M.D.S.)
in all cases.
The patency of the nasopharyngeal airway was assessed
clinically whilst the patient was breathing spontaneously
with no other aid to maintain airway patency and with the
other nostril occluded. Features indicating respiratory
obstruction such as see-sawing of the chest and abdomen,
rib recession and tracheal tug were sought and the degree
\ / ‘
Fig. 2. M’easurement of nares-epiglottis (NE) distance with
nasopharyngeal airway in siru.
of obstruction was recorded on a 0-2 scale (0 = no
obstruction, 1 = partial obstruction, 2 = total
obstruction).
An Obympus LF-I fibreoptic intubating laryngoscope
was inserted through the nasopharyngeal airway and
guided down to the vocal cords. When the tip of the
fibrescope was exactly between the vocal cords, a piece of
tape was put on the fibrescope at the nares (TI) as a
reference point for later measurement (Fig. I). The fibre-
scope was withdrawn to the tip of the epiglottis, and a
second piece of tape placed (T2) similarly (Fig. 2).
If the Fibrescope could not be passed (external diameter
4 mm) due to compression of the nasopharyngeal airway in
the nasopharynx, or if the larynx could not be seen, for
example because the tip of the airway was lodged in the
vallecula, then the fibrescope was passed down the other
nostril and the measurements made as before.
The nitsopharyngeal airway was removed and measured
in millimetres from the tip of the bevel to the flange. It was
inspected for blood streaking, and obvious bleeding into
the oropharynx was noted. Bleeding was scored on a 0-3
scale (0 = none, 1 = streaking, 2 = moderate, 3 =
severe, requiring suctioning). Following these observations
the patients were transferred to the operating theatre for
surgery.
The distances from the tip of fibrescope to the points TI
and T2 Isorrespond to the distance from the nares to the
rima glottidis of the larynx (nares-larynx distance, NL),
and to the distance from the nares to the tip of the
epiglotti:; (nares-epiglottis distance, NE), respectively. The
distance from the distal tip of the nasopharyngeal airway to
the vocal cords was calculated by subtracting the measured
length of the airway from the nares epiglottis distance.
In 23 patients, two additional measurements were made
(Fig. 3). With the nasopharyngeal airway in place and the
tip of the fibreoptic laryngoscope lying between the vocal
cords, the neck was gently flexed by an assistant until the
chin was resting on the chest. The new NL distance (NL2)
was then measured in the same way as before. The pillows
were removed and the patient’s neck was fully extended
 Nasopharyngeal airway position 577

Table 1. Mean (95% confidence intervals) values for patient

characteristics.
Age Height Weight
n years (cm) (kg)

Men 87 32 178 82
(29.5-35.3) (176.7-179.3) (79.4-84.5)
Women 33 35 163 68
(29.8-39.4) (160.9-165.7) (63.9-72.0)
Total 120 33 174 78
(30.5-35.5) (173.3-175.6) (75.7-80.6)

airway obstruction. In 72 patients (60%) the tip of the

Fig. 3. Measurement of effect of head flexion and extension on
nasolaryngeal length (a) normal position-measurement of NL;
(b) flexed position-measurement of NL2; (c) extended
position-measurement of NL3.
and again the NL distance was measured (NL3). The
relative movements due to flexion and extension of the
head and neck were then calculated by subtracting NL2
and NL3 from NL respectively.
Statistical analysis
Male and female data were analysed separately and
compared by unpaired Student’s t-testing. Multiple vari-
nasopharyngeal airway was found to be placed at or
beyond the epiglottis tip, and of these the tips of 16 (13%)
were lodged in the vallecula anterior to the epiglottis. Two
patients experienced complete obstruction (grade 2) with
the tip of the airway seen to be lodged in the vallecula.
Passage through the nasopharynx caused compression of
many of the airways and was sufficient to cause airway
obstruction in 19 cases (six women and 13 men). These
were patients in whom it was impossible to pass the fibre-
scope through the nasopharyngeal airway due to narrowing
and so the other nostril had had to be used.
Upper respiratory obstruction occurred in a further three
subjects in whom the distal end of the nasopharyngeal
airway lay rostra1 to the soft palate behind the tongue. This
occurred when insertion of a larger nasopharyngeal airway
was unsuccessful and where a smaller (and therefore
shorter) airway had had to be used. One man had complete
respiratory obstruction with a size 6.0 airway for this
reason.
The cause of respiratory obstruction was identified in 38
of the 50 patients including three patients with complete
obstruction. The cause of airway obstruction in the other
12 patients was unclear but may have been a combination
of the above factors. None of the airways was obstructed
by blood, although two patients required suctioning
(Table 3).
Table 4 presents the airway measurement data. The
distributions of nares-larynx and nares-epiglottis distances
in men and women are shown as cumulative relative
frequency histograms in Figures 4 and 5 respectively.
Multivariate backward stepwise linear regression analysis
revealed a significant correlation between nares-epiglottis
distance and height (t = 3.90, p = 0.0002), but no signifi-
cant correlation between nares-epiglottis distance and
Table 2. Sizes and positions of nasopharyngeal airways.
~

able backward stepwise linear regression analysis [6] of the Nasopharyngeal airway 6.0 7.0 8.0 Total
data was performed using the Statgraphics computer internal diameter; mm
Length (range); mm 125-135 145-155 165-175
software package [7] to attempt to find a relation between
nares-epiglottis or nares-larynx distances and height, Number used male 5 36 46 87
weight, naso-mandibular, naso-tragus, and thyro-mental female 8 25 - 33
distances. The flexion/extension data were analysed by all 13 61 46 120
paired Student’s t-testing. A p level of less than 0.05 was Beyond male 0 10 43 53
epiglottis female 2 17 - 19
taken as statistically significant. all 2 27 43 72
In vallecula male 0 1 10 11
Results female 0 5 - 5
all 0 6 10 16
One hundred and twenty patients were studied (Table 1). Respiratory male 4 I1 21 36
obstruction female 3 11 - 14
Details of the nasopharyngeal airway sizes and positions
a11 7 22 21 50
are shown in Table 2. ~

Fifty patients (42%) had clinical evidence of upper - = not used

518 M.D . Stoneham
Table 3. Number (YO) of patients in whom introduction of the Table 5. Relative movements of the nasopharyngeal airway
nasopharyngeal airways caused bleeding. (n = 120). towards (+) and away from (-) the larynx during flexion and
extension of the head and neck. Values are expressed as mean
Nasopharyngeal airway 6.0 7.0 8.0 All (95Y0 confidence intervals) (n = 23).
internal diameter
(mm) Relative movement mm

Grade 0 (none) 5 (4) 42 (35) 35 (29) 82 (68)
Grade I (streaking) 4 (3) 16(13) 9 (8) 29 (24)
Grade 2 (moderate) 1 (1) 3 (3) 3 (3) 7 (6)
Grade 3 (severe) 2 (2) 0 (0) 0 (0) 2 (2)
weight (t = -0.70, p = 0.49), naso-mandibular (t =
- 1.10, p = 0.27), naso-tragus (t = 1.79, p = 0.08) or
thyro-mental (t = -1.03, p = 0.30) distances. The
relationship between nares-epiglottis distance and height is
shown in Figure 6 and is represented by:
NE(mm) = -5.38+0.915 x HEIGHT(cm)
(r = 0.478. p = 0.0002).
95% confidence intervals for the intercept were -60.5 to
49.7 and for the slope of the line were +0.60 to 1.23. +
Twenty-three patients entered the last part of the study
(Table 5).* The mean measured alteration in position of the
nasopharyngeal airway tip from the ‘anaesthetic’ position
with two pillows supporting the head and neck relative to
the flexed position was +5.7 mm (p < 0.001). The mean
measured alteration in position from ‘anaesthetic’ to the
+
extended position was 1.3 mm (p > 0.2). The change in
position of the airway when the head was moved from fully
flexed to fully extended was -4.4 mm (p < 0.05).
Although two of these show significant changes in position
the movement is very small and unlikely to be important
clinically.
Discussion
The incidence of upper airway obstruction through the
nasopharyngeal airway was high in this study, although it
must be emphasised that this was enhanced by occlusion of
the other nostril and mouth. In practice, upper airway
obstruction is probably less common because of alternate
routes of ventilation through the nose and mouth.
There are several potential problems associated with a
nasopharyngeal airway which is in the wrong position or is
too long. Upper airway obstruction was caused in 13% of
patients by the tip of the airway lying in the vallecula in a
similar fashion to that described for the Guedel oropharyn-
geal airway where up to 20% have been reported as simi-
larly malplaced [8]. A nasopharyngeal airway which is too
long may enter the oesophagus, with the associated
problems of hypoxia and gastric distension. Accidental
introduction of the nasopharyngeal airway to the larynx
neutral + flexed +5.7 (3.4-8.0)
neutral + ex.tended +1.3 ( - 2 . 1 4 . 6 )
*A positive value indicates that there is an increase in
nares-laryngeal length when the head is moved from the neutral
position to flexed or extended; a negative value represents the
converse.
may stimulate laryngeal reflexes leading to coughing or
laryngospasm particularly during light planes of anaes-
thesia or during recovery, when nasopharyngeal airways
are commonly used. This was not seen in this study as the
patients were all anaesthetised to a plane of surgical anaes-
thesia during insertion and measurement.
In addition to this there were the other causes of upper
airway obstruction. Compression of the airway in the nose
is a feature of patient anatomy rather than tube design, but
obstruction by the tongue and soft palate should be avoid-
able if nasopharyngeal airway length is more independent
of internal diameter. There is a requirement for a longer,
narrow nasopharyngeal airway for patients in whom for
anatomical reasons, it is impossible to pass the larger
diameter .airways.
These problems can be avoided if the tip of the airway
lies rostra.1 to the epiglottis as described by Gallagher and
colleagues [4].
Several groups have attempted to optimise the position
of the distal end of the airway using a cuffed version [9,10].
This type of preformed nasal tube is inflated in the hypo-
pharynx in a similar fashion to the laryngeal mask airway.
In patients with patent airways, an average length of 14 cm
from narcs to the tip of the airway was found, but no data
were reported concerning the position of the distal end of
the airway in relation to laryngeal structures.
It was disappointing that in the study reported here no
relation was found between the required length of artificial
nasopharyneal airway and simple anthropometric measure-
ments. The relation to height is not unexpected. In the only
previous study attempting to correlate length of the
patient’s nasopharyngeal airway with external measure-
ments of the face [I I], a nasotracheal tube was used to
measure the nares+epiglottis distance. The assessments
unfortunately, were made by direct laryngoscopy, and
were, therefore, subject to distortion. Correlation was only
found between height and nares+epiglottis distance.
Movernent of tracheal tubes in relation to the carina with
flexion and extension of the neck is a well-recognised
problem particularly in neonates with their shorter

Table 4. Mean (%YOconfidence intervals) anatomical distances (mm) measured as described. p values refer to male/female differences.
Nares-larynx Nares-epiglottis Airway-lar ynx Naso-mandi bular Naso-tragus Thyremental

Men 209 159 50 148 154 78

(n = 87) (206.2-210.9) (156.1-161.2) (47.8-51.7) (146.7-149.9) (152.8-155.4) (75.8-79.6)
Women 180 140 40 I38 145 75
(n = 33) ( I 75.8-1 83.8) ( I 36.1-143.5) (37.3-42.6) (1 35.3- 140.2) ( 143.2- 146.7) (71.4-77.9)
Total 20 I I54 47 145 152 17
(n = 120) (197.6-203.7) ( I 50.9-156.0) (45.3-48.8) (143.8-146.9) (150.2-152.8) (75.2-78.5)
P c 0.001 < 0.001 c 0.001 < 0.001 c 0.001 c 0.2
 Nasopharyngeal airway position 579

" 164 169 174 179 184 189 194 199 204 209 214 219 224 229 234 239 244
Nares-larynx distance (mm)
Fig. 4. Cumulative relative frequency (CRF) histogram of nares-larynx distance in males (W. n = 87) and
females (I&n = 33).

100

80

60

20

0
119 124 129 134 139 144 149 154 159 164 169 174 179 184 189 194
Nares-epiglottis distance (mm)
Fig. 5. Cumulative relative frequency (CRF) histogram of nares-epiglottis distance in males (W, n = 87) and
females (El, n = 33).

2001
190

180 1
+ ++ +-+/
t f +
t
t

+ + +;/ * + +

'"t
150

140 1 I I
+

I
+ +

I I
+

I I I I I
100 110 120 130 140 150 160 170 180 190 200
Nares-epiglottis distance (mm)
Fig. 6. Relation between nares-epiglottis distance (NE) and height. NE = -5.38+0.915 x height ( r = 0.478;
p = 0.0002).
580 M.D . Stoneham
larynx-carina distance and can lead to extubation, or
intubation of the right main bronchus. In previous adult
studies [ 121 in which distances were measured from
cadavers and chest radiographs, movements of up to 5 cm
were recorded on flexion and extension of the head and
neck. The relative movement of a nasopharyngeal airway
has not been investigated previously, but might be expected
to be less than that seen with a tracheal tube, due to the
shorter length. The alterations in position seen in this study
were statistically, but not clinically, significant and
occurred in both directions.
The incidence of bleeding found in this study was
comparable to that found by others [4,10] with fresh
bleeding occurring in 5 to 10% of patients and streaking in
UP to 30%.
It is recognised that there were some limitations with this
study, Firstly, the distribution of patients was biased
towards young, fit males. Secondly, the relationship
between laryngeal structures and anaesthetic airways is
obviously influenced by head position. It would have been
desirable to have standardised the head positioning more
precisely than was done, although the third part of the
study suggested that this was not as important as
previously thought. Thirdly, it would have been desirable
to have used a more accurate assessment of airway obstruc-
tion through the nasopharyngeal airway than the three
point clinical scale which was used. Despite these limita-
tions, there are clear conclusions which may be drawn.
The ideal position for the distal tip of the nasopharyn-
geal airway is within 1 cm of the epiglottis tip as this will
then avoid most of the complications mentioned
previously. From Figure 5 it is apparent that lengths of
nasopharyngeal airways of 150 mm for males and 130 mm
for females are appropriate for most patients. However, the
variation in nares-epiglottis distance is such that one size
will not be appropriate for all patients. One solution would
be to manufacture all airways to the same length, for
example 160 mm, with a range of diameters, and alter the
length of airway to be inserted by means of the safety pin.
The external surface of the airways should be marked in
centimetres in a similar fashion to tracheal tubes, so that
the length of nasopharyngeal airway that has been inserted
is immediately apparent.
This study has shown that the position of the distal end
of nasopharyngeal airways relative to structures in the
hypopharynx is unpredicable and that this may detract
from their ability to maintain a patent airway. This means
that there should be a greater awareness of the risk of
respiratory obstruction even with the airway in place.
Acknowledgments
The author thanks Dr M.E. Wilson, PhD, FFARCS for his
helpful advice during the planning of the project. The
cooperation of the Operating Department Assistants of the
Royal Naval Hospital, Plymouth is gratefully
acknowledged.
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