Nasotracheal intubation is a viable alternative method of securing the airway for most routine surgical cases requiring intubation, is preferred in some instances, and more readily facilitates prolonged ventilator weaning. The authors describe a case of inadvertent intracranial placement of a nasotracheal tube in a patient with undiagnosed congenital absence of the bony cribriform plate.
A 32-year-old blind, severely mentally challenged female with cleft lip, cleft palate, and dental caries presented for oral examination under anesthesia and possible multiple dental extractions. The skull radiograph taken in the operating room showed that an endotracheal tube had traversed a large postnasal cystic cavity and the tip appeared in the cranial vault. Following removal of the tube, free-flowing cerebrospinal fluid was noted to be leaking from the nares. Urgent computed tomographic scan revealed complete congenital absence of the midline skull base. The patient was transferred to the intensive care unit where her condition deteriorated. The first day after discharge to a longterm care facility, she suffered a poorly described “respiratory event” and died.
Upon retrospective analysis of the case, the authors believe the patient had a variant of Goldenhar syndrome. Computed tomographic scan demonstrated absence of the bony cribriform plate, and the absence of an intact skull base was a primary cause in the intracranial placement of her breathing tube. An analysis of accidental intracranial nasogastric and nasotracheal cases has shown that in 71% of cases the tube enters the cranial vault through a defect in the cribriform plate.
Important Findings: Vigilance is needed in the placement of nasogastric and nasotracheal tubes in patients with congenital abnormalities or malformations of craniofacial development since these patients may have bony defects that increase the risk of intracranial misplacement of nasally introduced tubes. The authors believe, “It would be advisable to obtain imaging studies in patients with known or suspected craniofacial abnormalities to confirm intact bony architecture of the skull base before any nonemergent procedure for which nasogastric placement or nasotracheal intubation is planned.
