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| LETTER TO EDITOR |
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| Year : 2010 | Volume
: 58
| Issue : 5 | Page : 804-805 |
Intracranial introduction of a nasogastric tube in a patient with severe craniofacial trauma
Ramesh Chandra, Phani Kumar
Department of Neurosurgery, GSL Medical College and General Hospital, Rajahmundry, India
| Date of Acceptance | 01-Feb-2010 |
| Date of Web Publication | 28-Oct-2010 |
Correspondence Address:
Ramesh Chandra
Department of Neurosurgery, GSL Medical College and General Hospital, Rajahmundry
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.72192
How to cite this article:
Chandra R, Kumar P. Intracranial introduction of a nasogastric tube in a patient with severe craniofacial trauma. Neurol India 2010;58:804-5 |
Sir,
Malpositioning of nasogastric tube (NGT) intracranially is a rare complication and usually occurs in patients with skull base fractures, but when it occurs it can be hazardous, and even fatal. We report a 45-year old male patient who sustained severe craniofacial trauma in a motor vehicular accident and was referred to our trauma care unit from a peripheral health centre after basic resuscitation. On admission, the patient was hemodynamically unstable, unconscious with a Glasgow Coma Scale score of 4. Skull radiography [Figure 1] revealed multiple craniofacial fractures and surprisingly, the nasogastric tube intracranially. The nasogastric tube was removed through the nose. In view of his poor neurological status and hemodynamic instability, patient was admitted to the intensive care unit and was put on mechanical ventilatory support. However, he succumbed to injuries on the second day of admission.
The placement of a NGT is a common practice in trauma surgery, however, in some cases it may not receive due attention. Numerous complications associated with the use of NGT have been reported, the most common being inadvertent insertion of the NGT into the trachea and distal airways. [1] Though the inadvertent placement of an NGT into the intracranial cavity was first described by Seebacher et al. [2] in 1975 with fatal consequences for the patient, it is albeit rare. [3] These instances have been seen in numerous clinical settings, most commonly trauma, following basal skull fractures and complex craniofacial injuries. [4] Moustoukas described two etiological factors as possible causes of intracranial displacement of a nasogastric tube: a basilar fracture extending through the cribriform plate, and thin cribriform plate perforation by a rigid tube.[5] The consequences of inadvertent NGT positioning within the cranial cavity are serious, with a reported mortality rate of 64%, and morbidity in the form of hemi paresis, blindness, loss of the sense of smell, or persistent cerebrospinal fluid fistulas. [6]
The procedure for removing an intracranial NGT is debated. Some authors recommend craniotomy with removal of the tube under direct visualization [6] others advocate retrieval through the nose. [7] No scientific evidence is presently available to suggest that either technique offers any prognostic advantages. In any case, the best approach is clearly to prevent this complication in the first place. The placement of an NGT is often first evaluated by aspirating the fluid or insufflating air and auscultation of the abdomen to induce a "pseudo-confirmation gurgle." [8] Both maneuvers may yield false-positive results thus making physical examination a poor predictor of tube malpositioning, especially in an unconscious patient.[8] To eliminate the possibility of this complication, numerous measures have been described including nasogastric intubation under fluoroscopic guidance, [9] endoscopic guidance, [9] or direct vision. [10] The orogastric tube is another option. [10]
| » References | |  |
| 1. | Sliwa JA, Marciniak C. A complication of nasogastric tube removal. Arch Phys Med Rehabil 1989;70:702-4. 
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| 2. | Seebacher J, Nozitk D, Mathieu A. Inadvertent introduction of a nasogastric tube, a complication of severe maxillofacial trauma. Anesthesiology 1975;42:100-2.
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| 3. | Arslantas A, Ramazan D, Erhan C, Esref T. Inadvertent insertion of a nasogastric tube in a patient with head trauma. Child's Nerv Syst 2001;17:112-4.
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| 4. | Sacks AD. Intracranial placement of a nasogastric tube after complex craniofacial trauma. Ear Nose Throat J 1993;72:800-2.
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| 5. | Moustoukas N, Litwin MS. Intracranial placement of nasogastric tube: an unusual complication. South Med J 1983;76:816-7.
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| 6. | Fletcher SA, Henderson LT, Miner ME, Jones JM. The successful surgical removal of intracranial nasogastric tubes. J Trauma 1987;27:948-52.
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| 7. | Freij RM, Mullett ST. Inadvertent intracranial insertion of a nasogastric tube in a non-trauma patient. J Accid Emerg Med 1997;14:45-7.
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| 8. | Thomas B, Cummin D, Falcone RE. Accidental pneumothorax from a nasogastric tube. N Engl J Med 1996;355:1325.
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| 9. | Bhattacharyya N, Gopal HV. Examining the safety of nasogastric tube placement after endoscopic sinus surgery. Ann Otol Rhinol Laryngol 1998;107:662-4.
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| 10. | Adler JS, Graeb DA, Nugent RA. Inadvertent intracranial placement of a nasogastric tube in a patient with severe head trauma. Can Med Assoc J 1992;147:668-9.
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