We read with great concern the image case presented by Patel et al. describing the intracranial misplacement of a nasogastric tube in a nontrauma patient with a history of chronic alcoholism. As anesthesia care providers, we acknowledge the importance of addressing this critical issue further in nontrauma patients to improve patient safety.

In recent years, the increased demand for nasal swab testing during the COVID-19 pandemic has highlighted the risk of skull base injuries caused by misplaced nasogastric tubes and nasal swabs. Both cases share similar mechanisms, with the cribriform plate region at the roof of the nasal cavities being particularly vulnerable due to its thinness and its perforations by olfactory nerves. 

To proactively prevent intracranial misplacement of nasogastric tubes, we propose a straightforward approach based on anatomic knowledge. First, do not go into the roof of the nasal cavities. After inserting the nasogastric tube, carefully advance it toward the direction of the external auditory meatus, which runs parallel to the hard palate. This will help avoid advancing the tube into the cranial vault through the cribriform plate. Second, see it through the pharynx. Once the tube’s depth of insertion reaches the distance to the external auditory meatus, the distal end should be visible in the oropharynx. A video-laryngoscope can assist in guiding the tube into the esophageal inlet, minimizing the risk of tracheobronchial misplacement or retropharyngeal mucosal perforation. 

By emphasizing adherence to standard procedures and avoiding the cribriform plate region, we believe that this approach can substantially reduce the occurrence of intracranial misplacement of nasogastric tubes. Medical practitioners should be aware of this risk and implement these preventive measures in routine clinical practice to enhance patient safety.