Intracranial Nasogastric Tube Placement in a Nontrauma Patient

Nasogastric tube placement is not without risk. A patient admitted for severe hyperemesis in the setting of chronic alcoholism required nasogastric tube placement. Immediately after nasogastric tube placement, his mental status changed dramatically, and he was urgently intubated by an anesthesiologist. Computed tomography imaging (fig. 1) demonstrated the intracranial placement of a nasogastric tube. Neurosurgery was consulted, and it was removed under direct visualization. Although unintended intracranial placement of an nasogastric tube is rare, it has been reported several times, dating back to the 1970s.  Almost all of these cases, however, were due to facial or head trauma.  Evidence suggests that drug use, specifically cocaine, and chronic alcohol abuse can lead to midfacial anatomical deformities over time, including thinning of the cribriform plate, rendering these patients at risk.  Anesthesiologists regularly place nasogastric tubes in the perioperative setting. As such, one must understand that, although nasogastric tube placement is considered routine, other complications could arise such as perforation or injury of the nasopharyngeal and laryngeal structures, esophagus, stomach, trachea, mediastinum, and lungs, and associated bleeding.  Although erroneous intracranial nasogastric tube placement is rare and often seen in trauma patients, nasogastric tube placement should be performed cautiously in patients with chronic drug or alcohol use due to the risk of midfacial anatomic abnormalities. Although preventing this complication can be difficult, advancing the nasogastric tube with its tip parallel to the hard palate plane and ensuring no cephalad insertion are critical. Those with facial trauma or possible deranged anatomy may benefit from fiberoptic or endoscopic placement  or placement through a nasopharyngeal airway.