(278) Intracranial Injury Following Attempted Nasogastric Tube Placement After Transsphenoidal Surgery

Introduction: Inadvertent intracranial nasogastric tube (NGT) placement is a known risk after facial trauma resulting in skull base fracture; however, history of skull base surgery presents another significant risk factor for this potentially fatal complication.

Methods: We present the case of a 75-year-old patient admitted with C difficile colitis six months after endoscopic endonasal resection of a pituitary macroadenoma. Sellar reconstruction consisted of epidural inlay of a dural substitute. During admission for colitis, NGT placement was attempted multiple times, after which the patient became obtunded and was placed on positive pressure ventilation with subsequent imaging demonstrating tension pneumocephalus. The patient was transferred to our academic institution for management. Endoscopic exam demonstrated a defect at the site of previous repair and cerebrospinal fluid leak most consistent with traumatic injury. The patient underwent successful repair with a nasoseptal flap, however, ultimately showed no signs of neurologic recovery with repeat imaging showing evolving pontine hemorrhage. She was terminally extubated 18 days after injury. We also present a review of the literature regarding intracranial NGT insertions in patients with skull base defects.

Results: Literature review revealed five cases of intracranial NGT placement and one intracranial nasotracheal tube placement after skull base surgery as well as two cases after other sinonasal procedures (septoplasty, unilateral choanal atresia repair). Cadaver studies show durable middle turbinate medialization and use of small-bore flexible feeding tubes, when possible, may improve skull base protection post operatively.

Conclusions: Patients, families, and providers should be educated of the potential consequences of blind nasal procedures in patients with a history of skull base surgery.