When doing nasogastric (NG) tubes and fiberoptic nasopharyngoscopy (NP) procedures, there many approaches in how patients can be locally anesthetized. Getting things pushed up your nose is so profoundly irritating that most patients only give you 1 or 2 changes to get it right.

One option is to use nebulized lidocaine, although it takes a while to prepare and anecdotally tends to numb mainly the hypopharynx, placing the patient at risk for aspiration later on. Another option is to use viscous lidocaine to coat the NG or NP tubing, but this is fairly messy and only mildly helpful. Commercial intranasal atomizers, which disperse lidocaine over the nasal mucosal surfaces well, are generally effective, but may not be available in some emergency departments.

Trick of the Trade:

Make your own intranasal lidocaine-oxymetazoline spray

Put 5-10 mL of 1-2% lidocaine into a new oxymetazoline spray bottle with a 25g needle. The oxymetazoline provides great vasoconstriction and thus mucosal edema reduction. It also provides great hemostasis in case you cause a little intranasal trauma.  

Insufflate the oxymetazoline spray bottle 2-3 times into the patient’s nose to atomize the anesthetic plus vasoconstrictive medication mixture. The solution is perfectly atomized and anesthetizes the painful areas. Anecdotally, most people have excellent anesthesia in just a few minutes.  

Thanks to Dr. Matt Wong (@MatthewLWong), an EM resident at BIDMC/HAEMR in Boston for sharing this trick. He asserts that, “Since using this method my rates of painless and successful NG tube insertions has gone way up. FYI, I also still use a water-based lubricant on the NG tube to facilitate the insertion process.”

Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at https://t.co/50EapJORCa Bio: https://t.co/7v7cgJqNEn
Michelle Lin, MD