Dear Sirs,

We enjoyed reading the above article by Der Kureghian et al.,Reference Der Kureghian, Kumar and Jani¹ as we are aware that blind passage of nasogastric tubes has limitations, particularly in post-operative patients and those with neurological pathology.

A number of other techniques can be used in patients in whom nasogastric tube insertion is difficult. We follow the technique described by Srouji et al.,Reference Srouji and Ingrams² in which a Blom–Singer 16 Fr gel cap is used to secure a fine bore feeding tube to a flexible fibre-optic nasendoscope. The gel cap is fashioned into an open cylinder by cutting away its dome. This is then used as a band holding the nasendoscope and the fine bore feeding tube together 5 cm away from their tips. A further gel cap is fenestrated at its dome just enough to allow the tip of the nasendoscope to protrude by 2 mm. The tip of the fine bore feeding tube is inserted inside the fenestrated gel cap. Nasendoscopy proceeds, and the patient is asked to swallow the tip of the endoscope while the operator ensures its position away from the airway and down one of the pyriform fossae. The endoscope is held in position for 2–3 minutes to allow the gel caps to dissolve. The nasogastric tube is then advanced, assisted by the patient's swallowing. The endoscope is withdrawn after a final check on the nasogastric tube position.

If gel caps are not available, a further technique which we have found useful when passing a fine bore feeding tube is to use the flexible tip of the nasendoscope to position the nasogastric tube. A fine bore feeding tube is passed to the level of the pyriform fossa under flexible nasendoscope guidance. The flexible nasendoscope is then passed under the feeding tube and both tubes are advanced while the patient swallows. When the operator is convinced that the feeding tube has passed the cricopharynx, the flexible nasendoscope is withdrawn and the feeding tube is advanced to mark 55 and secured to the nose.