Available online at www.sciencedirect.

com

American Journal of Otolaryngology–Head and Neck Medicine and Surgery 33 (2012) 178 – 180
www.elsevier.com/locate/amjoto

Inadvertent insertion of nasogastric tube into the brain stem and spinal
cord after endoscopic skull base surgery☆,☆☆,★
Amgad S. Hanna, MDa , Christopher R. Grindle, MDb , Alpesh A. Patel, MDc ,
Marc R. Rosen, MDb , James J. Evans, MDd,⁎
a
Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
b
Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
c
Department of Orthopaedic Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
d
Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
Received 10 January 2011

Abstract A significant number of neurosurgical patients require feeding tube placement via a nasogastric
route. It is used as a temporary access for enteral feeding until patients are able to swallow or receive
permanent access. Despite how commonly feeding tubes are used, they are not without potential
complications. We report a case of inadvertent placement of small-bore feeding tube into the brain
stem and spinal cord in a patient with a history of previous endoscopic transnasal resection of clival
chordoma. We discuss the management of this complication and the strategies that have been
developed to avoid this complication in the future.
© 2012 Elsevier Inc. All rights reserved.

1. Introduction resected at another institution in 1996 via a craniotomy,

A significant number of neurosurgical patients require
feeding tube placement via a nasogastric route. It is used as a
temporary access for enteral feeding until patients are able to
swallow or receive permanent access via a percutaneous
esophagogastrostomy or open gastrostomy tube. Despite
how commonly feeding tubes are used, they are not without
potential complications. We report a case of inadvertent
placement of small-bore feeding tube into the brain stem and
spinal cord in a patient with a history of previous endoscopic
transnasal resection of clival chordoma.
2. Case report
A 57-year-old man presented with a recurrent clival
chordoma. The patient had a clival chordoma initially
☆
Financial disclosure: none.
☆☆
Conflict of interest: none.
★
Disclosure/disclaimer: The authors have no disclosures to report. The
authors have no conflict of interest to report.
⁎ Corresponding author. Department of Neurological Surgery, Thomas
Jefferson University Hospital, Philadelphia, PA, USA. Tel.: +1 215 955
7000; fax: +1 215 503 7007.
E-mail address: james.evans@jefferson.edu (J.J. Evans).
0196-0709/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjoto.2011.04.001
followed by radiation therapy to 70 Gy. Past medical history
included obesity, hypertension, hyperlipidemia, osteoarthri-
tis, and sleep apnea. The patient presented to our institution
with worsening headaches and gait difficulties. His neuro-
logical examination revealed left-sided ophthalmoplegia and
quadriparesis 4/5 on the right and 4+/5 on the left, with signs
of myelopathy. Magnetic resonance imaging revealed a
recurrent clival chordoma with extradural and intradural
components. The patient underwent an extended transnasal,
transclival endoscopic approach with intraoperative neuro-
navigation. Excellent tumor resection and brain stem
decompression were achieved. The patient's postoperative
and rehabilitation course was complicated by recurrent
pneumonia and interstitial pneumonitis, ultimately requiring
a right-sided thoracotomy for wedge resection of the middle
and lower lobes, meningitis, sepsis, and tracheostomy.
Because of the patient's large body habitus, the initial
attempt at percutaneous esophagogastrostomy tube place-
ment failed; and a nasogastric feeding tube was placed under
endoscopic visualization.
Several days later, the nasogastric feeding tube was
dislodged accidentally by the patient. The physician on call
replaced this with an identical-style nasogastric feeding tube.
 A.S. Hanna et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 33 (2012) 178–180 179

This was done at the bedside by the physician on call without
endoscopic visualization or other means of visualizing the tip
of the feeding tube from the nares to the esophageal inlet.
Immediately after placement, it was noted that the patient
was significantly weaker on his left side. Abdomen
radiograph revealed that the tip of the feeding tube was
below the level of the diaphragm. Computerized tomograph-
ic scan of the head revealed that the small-bore feeding tube
had violated the cranial base repair and entered the brain
stem and spinal cord (Fig. 1). The patient was taken to the
operating room, and the feeding tube was removed under
direct endoscopic visualization. After careful hemostasis,
minimal cerebrospinal fluid leak was noted. Dural repair was
accomplished with collagen grafts, fibrin glue, and abdom-
inal fat graft. The patient did not recover any motor strength
and remained quadriplegic, with only a mild left shoulder
shrug. An open gastrostomy tube was placed. Seven months
later, after a prolonged hospital course, the family withdrew
care and the patient died.
3. Discussion
The use of feeding tubes via a nasogastric route is a
frequent method of providing nutrition to neurosurgical
patients, especially in the intensive care unit. Devastated by
severe head injury, intracranial hemorrhage, or brain tumors,
many of these patients are unable to swallow. Whenever
possible, enteral feeding is preferred over parenteral feeding.
Complications of nasogastric tube placement are in the order
of 3.1% [1]. They include pneumothorax [2,3]; esophageal
perforation; knots in the feeding tube [4]; bleeding;
esophagitis; sinus infection; and inadvertent placement into
the lung, pleura [1], or the brain [5-15]. The risk of brain

Fig. 1. Axial (A and C) and sagittal (B and D) view computerized tomographic scans taken immediately following feeding tube placement showing course
of feeding tube through the clival defect and into the spinal cord. White arrows point to the feeding tube within the spinal canal.
180 A.S. Hanna et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 33 (2012) 178–180
Fig. 2. Algorithm for the use of enteral feeding tubes.
penetration is greater in patients with cranial base trauma or
anterior cranial base surgery. The complication rate is also
higher in the unconscious or noncooperative patient,
especially when using rigid small-bore feeding tubes. In
these cases, a number of devices and techniques are available
that permit visualization of the tube tip as it moves from nose
to esophageal inlet. Such techniques include flexible
nasopharyngolaryngoscopy, use of a simple intubation
laryngoscope, and/or fluoroscopy.
As is demonstrated in this case, failure of communication
is one of the main causes of medical errors. In our case, the
patient had pulled out his feeding tube and replacement was
requested. The physician on call was unaware that the
patient was scheduled for open gastrostomy tube placement
later that morning. In addition, information regarding the
recent cranial base surgery was not immediately apparent in
the patient's current chart or at the patient's bedside because
his admission was initially for pneumonia that he developed
while in rehabilitation. As a result of the analysis of this
event, our institution has adopted new policies to enhance
communication and prevent such adverse events. One of the
new procedures are bedside signs that will alert physicians
and nurses that the patient had an endoscopic transnasal
cranial base approach or a cranial base trauma. Currently, at
our institution, we have implemented a guideline concern-
ing the placement of small-bore feeding tubes in vulnerable
patients. At-risk patients are defined as those who are
intubated; have tracheostomies; are neurologically impaired;
have an altered mental status impairing their ability to
protect their airway; are determined, for any reason, to be
unable to protect their airway; or have anatomical
abnormalities that could preclude the safe passage of a
feeding tube. In this patient population, it is required that the
tip of the feeding tube be visualized directly, endoscopi-
cally, or radiographically as it passes from the nose to the
esophageal inlet. We are also exploring the possibility of
medical alert bracelets for patients with anterior cranial base
surgery or trauma to avoid inadvertent injury during
placement of feeding tubes via a nasogastric route and/or
nasotracheal intubation. This is of particular importance to
patients after endoscopic transnasal cranial base surgery, as
there are no external incisions or evidence of the underlying
surgical site. The following algorithm (Fig. 2) details the
process used at our institution when considering the use of
enteral feeding tubes.
References
[1] Lo JO, Wu V, Reh D, et al. Diagnosis and management of a misplaced
nasogastric tube into the pulmonary pleura. Arch Otolaryngol Head
Neck Surg 2008;134:547-50.
[2] Thomas B, Cummin D, Falcone RE. Accidental pneumothorax from a
nasogastric tube. N Engl J Med 1996;335:1325.
[3] Weinberg L, Skewes D. Pneumothorax from intrapleural placement of
a nasogastric tube. Anaesth Intensive Care 2006;34:276-9.
[4] Wien FE, Cooperman J. Images in clinical medicine: complications of
Cantor-tube insertion. N Engl J Med 2001;344:974.
[5] Arslantas A, Durmaz R, Cosan E, et al. Inadvertent insertion of a
nasogastric tube in a patient with head trauma. Childs Nerv Syst
2001;7:112-4.
[6] Başkaya MK. Inadvertent intracranial placement of a nasogastric tube
in patients with head injuries. Surg Neurol 1999;52:426-7.
[7] Cornett MA, Paris Jr A, Huang TY. Case report: intracranial
penetration of a nasogastric tube. Am J Emerg Med 1993;11:94-6.
[8] Freij RM, Mullett ST. Inadvertent intracranial insertion of a nasogastric
tube in a non-trauma patient. J Accid Emerg Med 1997;14:45-7.
[9] Galloway DC, Grudis J. Inadvertent intracranial placement of a
nasogastric tube through a basal skull fracture. South Med J 1979;72:
240-1.
[10] Genu PR, de Oliveira DM, Vasconcellos RJ, et al. Inadvertent
intracranial placement of a nasogastric tube in a patient with severe
craniofacial trauma: a case report. J Oral Maxillofac Surg 2004;62:
1435-8.
[11] Glasser SA, Garfinkle W, Scanlon M. Intracranial complication during
insertion of a nasogastric tube. AJNR Am J Neuroradiol 1990;11:1170.
[12] Metheny NA. Inadvertent intracranial nasogastric tube placement. Am
J Nurs 2002;102:25-7.
[13] Nathoo N, Nadvi SS. Intracranial malposition of a nasogastric tube
following repair of choanal atresia. Br J Neurosurg 1999;13:409-10.
[14] Pandey AK, Sharma AK, Diyora BD, et al. Inadvertent insertion of
nasogastric tube into the brain. J Assoc Physicians India 2004;52:
322-3.
[15] Rahimi-Movaghar V, Boroojeny SB, Moghtaderi A, et al. Intracranial
placement of a nasogastric tube. A lesson to be re-learned? Acta
Neurochir 2005;147:573-4.