When the Tube Won't Go: Strategies for Difficult Nasogastric Intubation

Nasogastric tube (NGT) insertion is a common yet sometimes technically challenging clinical procedure, essential in patients unable to swallow safely. Whilst generally straightforward, anatomical variations, prior surgery, trauma or neurological impairment may complicate the procedure. In such cases, otolaryngologists are often called upon to perform NGT placement under direct visualisation using flexible nasendoscopy (FNE). This narrative literature review examines adjunctive techniques and strategies available to enhance the success of difficult NGT insertions, particularly those performed under FNE guidance in awake patients. A comprehensive search was conducted using PubMed and Google Scholar, from 2005 to 2025, employing the MeSH term 'nasogastric tube' and other terms such as 'difficult insertion' and 'insertion technique'. Studies were included if they involved adult awake patients and described alternative or adjunctive methods to facilitate NGT placement, with studies being excluded from the literature review if they involved anaesthetised patients. Data were manually extracted by multiple authors on study design, technique and outcomes. Eleven relevant publications were identified. Techniques that increased success rates included prechilling or partially freezing the NGT to increase rigidity, the sniffing position, orientation, contralateral rotation and twisting (SORT) manoeuvre and FNE-assisted methods using surgical knots or dissolvable gel caps to guide the tube. Whilst these adjuncts demonstrated procedural efficiency and improved operator control, statistical improvement in success rates was not consistently shown. Nonetheless, patient comfort and procedural independence were notably improved with certain FNE-guided techniques. Difficult nasogastric intubation remains a significant clinical challenge. Evidence suggests that combining physical modifications to the tube with direct visualisation via FNE can enhance safety and efficiency, particularly in anatomically complex or high-risk patients. Although advanced adjuncts such as gel caps and surgical knots have not demonstrated definitive superiority, they offer practical advantages in selected cases. Further randomised controlled trials (RCTs) are warranted to evaluate their efficacy in awake patients and to establish standardised protocols for difficult NGT insertion.