Intracranial placement of a nasotracheal tube after transnasal trans-sphenoidal surgery

M. Paul*, M. Dueck, S. Kampe, F. Petzke and A. Ladra

Department of Anaesthesiology, University of Cologne, Joseph-Stelzmann-Str. 9, D-50931 Cologne, Germany

Corresponding author. E-mail: m.paul@uni-koeln.de

Accepted for publication: June 4, 2003


    Abstract
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Intracranial misplacement of a tracheal tube during attempted nasotracheal intubation is a rare, usually lethal complication. Such incidents are associated with fractures of the face and base of the skull. We report inadvertent intracranial placement of a nasotracheal tube in a patient who had 2 weeks previously undergone transnasal trans-sphenoidal surgery for a pituitary tumour. One should be aware that transnasal trans-sphenoidal surgery leaves a bony defect in the skull, which is susceptible to perforation by nasally introduced tubes.

Br J Anaesth 2003; 91: 601–4

Keywords: anaesthesia, neurosurgical; anaesthetic technique, nasotracheal intubation; complications, intracranial intubation


    Introduction
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Although orotracheal intubation is the most frequent route of tracheal intubation, nasotracheal intubation is also a routine procedure in anaesthesia and emergency medicine. Indications for nasotracheal intubation include impossible direct laryngoscopic visualization of the larynx, and in orofacial surgery requiring alignment of the patient’s dental occlusion.1 In our department, nasotracheal intubation was regularly performed in neurosurgical patients who were to be transferred to the intensive care unit (ICU) still intubated, for rewarming and weaning at the end of surgery. Nasotracheal intubation was employed as it allows secure fixation of the tracheal tube at the nose and decreases intratracheal movement of the tube during changes in patient position. According to the experiences of our neurosurgical ICU physicians and nurses, patients tolerate a nasotracheal tube better than orotracheal intubation, with less episodes of coughing and choking during prolonged weaning from ventilation. Coughing can lead to an undesirable albeit transient increase in intracranial pressure.2 However, nasotracheal intubation is not without risks: epistaxis, retropharyngeal dissection, and turbinectomy are known complications.3 A rare, but disastrous complication is the intracranial penetration of a nasotracheal tube, which has been reported in patients with traumatic fractures of the face and base of the skull.1 4 We report a case of inadvertent intracranial placement of a nasotracheal tube in a patient who previously had undergone transnasal trans-sphenoidal surgery for a pituitary adenoma.


    Case report
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
A 68-yr-old man was admitted to hospital with headaches and visual disturbances because of a large pituitary adenoma. He was to undergo a transcranial removal of the pituitary tumour. Two weeks previously, partial surgical removal of the tumour via a transnasal trans-sphenoidal approach (right nostril) had been performed. The patient was alert and able to follow complex commands. His preoperative haemoglobin level was 11.4 g dl–1. He was to be transferred, intubated to the ICU postoperatively.

In the operating room, the patient was placed in the supine position on the operating table, and electrocardiographic leads, a finger pulse oximeter (SpO2), and non-invasive arterial pressure cuff were attached. Immediately prior to induction of anaesthesia, the anaesthetist who was in charge of the case was called to take care of an emergency craniotomy in a trauma patient. As he had to rush to the emergency case, he only gave a brief report to the anaesthetist who took over this case, and did not mention that the previous partial hypophysectomy was performed trans-sphenoidally. The second anaesthetist decided to intubate this patient via the nasal route, as the patient was to be transferred to the ICU postoperatively.

Topical vasoconstriction and anaesthesia of the nasal passages were achieved by application of cocaine 5% solution. After preoxygenation with oxygen 100% for 3 min via a facemask, anaesthesia was induced with thiopental 350 mg and fentanyl 150 µg; vecuronium 7 mg was administered to facilitate intubation of the trachea. During exploration of the nasal passages, a lubricated rubber nasopharyngeal airway 8.0 mm could not be inserted into the right nostril without resistance, but was easily passed through the left nostril. The left nostril was therefore chosen for nasotracheal intubation.

During advancement of the nasotracheal tube through the left nostril, a slight resistance was felt. Rotation of the tube while trying to advance it further resulted in sudden, pulsating bleeding out of the proximal end of the tube. The oropharynx rapidly filled with blood. Immediate orotracheal intubation with a 7.5 mm tube was achieved while suctioning the oral cavity with two rigid suckers, and the patient was ventilated with oxygen 100%. The nasotracheal tube was then removed. The intense bleeding through the nose and mouth was stopped within 10 min by introducing a gauze tampon into the nose and upper pharynx. Hetastarch 6% 1500 ml was administered intravenously through additional peripheral 16 G catheters to compensate for the blood loss. The haemoglobin level fell transiently to 6.7 g dl–1, but increased to 8.8 g dl–1 after transfusion of two units of packed red blood cells, which were transfused within 20 min of the onset of haemorrhage. During the acute bleeding phase the arterial pressure fell to 80/40 mm Hg for several minutes, but returned rapidly to 110/65 mm Hg after volume resuscitation. Four additional units of packed red blood cells and five units of fresh frozen plasma were transfused within 45 min of the onset of bleeding to correct the haemoglobin level.

A neurological examination, performed about 25 min after the onset of bleeding, revealed bilateral dilated pupils with no response to light. An increase in intracranial pressure because of intracranial haemorrhage was suspected. Cranial computer tomography was performed immediately and showed large amounts of blood in the third and fourth ventricle, and in the basal cysterns and around the brainstem (Fig. 1). The surgical team decided that the haemorrhage could not be stopped by surgical intervention. An external ventricular drain was inserted into the left ventricle to reduce the intracranial pressure (ICP) and to monitor it. The initial ICP was raised at 35 cm H2O and the cerebrospinal fluid was bloodstained. After placement of the external ventricular drain, the patient was transferred to the ICU. About 7 h after the bleed, an electroencephalogram showed minimal spontaneous activity and auditory evoked potentials indicated severe brainstem disturbance. The patient remained unconscious and died 4 days later as a result of the severe intracranial sequelae. An autopsy was refused by the patient’s family.



View larger version (153K):
[in this window]
[in a new window]
 
Fig 1 Axial computed tomography image showing blood (indicated by arrows) around the brainstem

 

    Discussion
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Nasotracheal intubation is an effective technique and an alternative to orotracheal intubation. It can be used if mouth opening is impaired, making direct visualization of the larynx using a laryngoscope impossible, or if maxillomandibular occlusion is required for reconstruction of maxillofacial injuries. Blind nasotracheal intubation is often used in the pre-hospital setting by paramedics and for emergency airway control.5 Nasotracheal intubation allows secure fixation of the tube at the nose, and decreases intratracheal movement of the tube during patient positioning and therefore potential tracheal injury. According to our experience, patients tolerate nasotracheal intubation better than orotracheal intubation during prolonged recovery and weaning from ventilation, resulting in less episodes of coughing, which should be avoided after intracranial surgery. Many patients in our neurosurgical ICU are therefore nasally intubated. Following major intracranial surgery, most of our patients are admitted postoperatively to our neurosurgical ICU for 24 h for monitoring of their neurological status and vital signs. After long neurosurgical operations, which are performed under opioid-based general anaesthesia, it is not uncommon to transfer a patient intubated to the ICU, in order to control their ventilation during transport, as hypercapnia should be avoided. In addition, rapid transfer of an intubated patient does allow more efficient use of operating theatre capacity.

However, there are recognized complications of nasotracheal intubation, which can be classified as nervous, occlusive or traumatic.1 Nervous system complications such as cardiac dysrhythmias or occlusive complications such as oesophageal intubation, can also occur with orotracheal intubation, but traumatic complications are more likely with nasotracheal intubation. Epistaxis is the most common complication and can lead to significant haemorrhage.5 Avulsion of the adenoids or tonsils, retropharyngeal dissection, turbinectomy, tracheal lacerations, and vocal cord injury are also known complications.3 5 6

A rare, but severe complication is the inadvertent intracranial placement of a nasotracheal tube. To date, three such cases have been reported.1 4 7 Two of these cases were associated with severe fractures of the face and base of the skull, and the third case was an apparently routine intubation in a neonate. In all three cases, the nasotracheal tubes entered the anterior fossa. The two adult trauma patients subsequently died, whereas the child survived with severe neurological sequelae.

In contrast, inadvertent intracranial placement of a nasogastric tube has been described more frequently with over 40 reported cases (for review see1 8). The higher frequency of nasogastric tube misplacements may be a result of their finer diameter compared with tracheal tubes.9 Intracranial placement of a Foley catheter, introduced into the nose to stop severe epistaxis, has been reported twice.10 11 Consequences of tube placement into the cranial cavity are severe, with a mortality of over 50%.1 8 Serious complications such as hemiparesis, blindness, loss of the sense of smells, or cerebrospinal fluid fistulae may occur.12 The vast majority of inadvertent intracranial tube placements are associated with fractures of the face and skull.

The presence of facial trauma with actual or suspected basilar skull fractures has traditionally been a contraindication to nasotracheal intubation.13 However, this paradigm has recently been challenged and some authors claim that it is based only on anecdotal reports.14 In a review of 160 patients with fractures of the base of the skull, Bähr and Stoll found no difference in complications following intubation by the nasal compared with the oral route.15 Similar findings have been reported by other investigators in more recent studies.16 On the other hand, Bracken argues that the reason why reports of inadvertent intracranial tracheal tube placements are so rare, is because of the long established paradigm, that suspected or known fractures of the base of the skull constitute a contraindication to nasal intubation.17

In our case, the integrity of the skull base was not altered by trauma, but by previous transnasal trans-sphenoidal surgery for a pituitary tumour, which left a bony defect in the skull and allowed the nasotracheal tube to penetrate the sphenoid sinus. To our knowledge, such an inadvertent intracranial placement of a nasotracheal tube has not been described previously. One case of an intracranial malpositioning of a nasogastric tube 5 days after transnasal trans-sphenoidal surgery has been reported.18 That patient died 2 days after misplacement of the tube, but had been in a compromised state before the event. Guerra and co-workers described the intracranial misplacement of a nasogastric tube in a patient with a large pituitary tumour that had eroded the base of the skull.19 The case we present led to a review of the advantages and disadvantages of nasotracheal intubation in our institution, resulting in more restricted indications for it.

Recommendations for nasotracheal intubation state that insertion and advancement of the tube should be strictly along the floor of the nasal cavity.14 This technique is recommended to avoid penetration of the cranial vault, which was reported to occur, in 71% of cases, via the cribriform plate.12 In addition, we use a soft, rubber nasopharyngeal tube, and assess both nostrils in order to find the more appropriate one for nasal intubation, as deviation of the nasal septum is not uncommon. The nasopharyngeal tube is usually lubricated with gel containing lidocaine 2% to provide local anaesthesia to the nasal passage. The left nostril appeared to be the more appropriate for nasal intubation in this patient and although recommendations for advancing the tube were followed, its tip was still guided towards the sella. It is not unusual to encounter a degree of resistance when passing a nasotracheal tube. Partial rotation of the tube is a manoeuvre frequently employed to overcome such resistance and guide the tube to its correct position.7 Unfortunately, this manoeuvre resulted in perforation of the sphenoid sinus, causing laceration of the carotid artery and severe intracranial haemorrhage. Various techniques such as using a thin nasogastric tube as a guide or warming the nasotracheal tube to soften it have been suggested to facilitate nasotracheal intubation and decrease traumatic complications. It remains unknown whether using one of these techniques would have prevented this lethal complication in our patient.

Given the previous surgical history, nasotracheal intubation should have been avoided in this patient. The anaesthetist initially undertaking to do the case was called to take care of an emergency craniotomy and provided the second anaesthetist with an incomplete history of the patient’s previous partial hypophysectomy, which was done trans-sphenoidally. This tragic deficit in communication led to the decision of the second anaesthetist to intubate the patient via the nasal route, which was routine practice in our department. However, it is the duty of every anaesthetist to ensure that they correctly understand the past history and present condition of every patient to whom they are providing care. Appropriate communication between colleagues is very important if the anaesthesia care provider changes, in order to avoid adverse outcomes.

One should be aware that transnasal trans-sphenoidal surgery creates a defect in the bony skull. Patients who have previously undergone this type of surgery are predisposed to a higher risk of intracranial misplacement of nasally introduced tubes. Nasotracheal intubation should therefore be avoided in these patients.


    References
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
1 Marlow TJ, Goltra DD, Jr, Schabel SI. Intracranial placement of a nasotracheal tube after facial fracture: a rare complication. J Emerg Med 1997; 15: 187–91[CrossRef][Medline]

2 Gemma M, Tommasino C, Cerri M, et al. Intracranial effects of endotracheal suctioning in the acute phase of head injury. J Neurosurg Anesthesiol 2002; 14: 50–4[CrossRef][ISI][Medline]

3 Moore DC. Middle turbinectomy: a complication of IMPROPER nasal intubation? Anesthesiology 2000; 92: 1504–5

4 Horellou MF, Mathe D, Feiss P. A hazard of naso-tracheal intubation. Anaesthesia 1978; 33: 73–4

5 Tintinalli JE, Claffey J. Complications of nasotracheal intubation. Ann Emerg Med 1981; 10: 142–4[ISI][Medline]

6 Chait DH, Poulton TJ. Case report: retropharyngeal perforation, a complication of nasotracheal intubation. Nebr Med J 1984; 69: 68–9[Medline]

7 Cameron D, Lupton BA. Inadvertent brain penetration during neonatal nasotracheal intubation. Arch Dis Child 1993; 69: 79–80[Abstract]

8 Gianelli Castiglione A, Bruzzone E, Burrello C, et al. Intracranial insertion of a nasogastric tube in a case of homicidal head trauma. Am J Forensic Med Pathol 1998; 19: 329–34[CrossRef][ISI][Medline]

9 Bhattacharyya N, Gopal HV. Examining the safety of nasogastric tube placement after endoscopic sinus surgery. Ann Otol Rhinol Laryngol 1998; 107: 662–4[ISI][Medline]

10 Engel M, Reif J, Moncrief E. Inadvertent intracranial placement of a Foley catheter. A rare iatrogenic complication of severe frontomaxillary trauma. Rev Stomatol Chir Maxillofac 1992; 93: 333–6[Medline]

11 Pawar SJ, Sharma RR, Lad SD. Intracranial migration of Foley catheter—an unusual complication. J Clin Neurosci 2003; 10: 248–9[CrossRef][ISI][Medline]

12 Fletcher SA, Henderson LT, Miner ME, Jones JM. The successful surgical removal of intracranial nasogastric tubes. J Trauma 1987; 27: 948–52[ISI][Medline]

13 Stone DJ, Gal TJ. Airway management. In: Miller RD, ed. Anesthesia, 5th Edn. New York: Churchill Livingstone, 2000; 1414–51

14 Goodisson DW, Shaw GM, Snape L. Intracranial intubation in patients with maxillofacial injuries associated with base of skull fractures? J Trauma 2001; 50: 363–5[ISI][Medline]

15 Bahr W, Stoll P. Nasal intubation in the presence of frontobasal fractures: a retrospective study. J Oral Maxillofac Surg 1992; 50: 445–7[ISI][Medline]

16 Rosen CL, Wolfe RE, Chew SE, Branney SW, Roe EJ. Blind nasotracheal intubation in the presence of facial trauma. J Emerg Med 1997; 15: 141–5[CrossRef][Medline]

17 Bracken CA. Base of skull fractures and intubation: archaic medicine or sound rationale? J Trauma 2001; 50: 365–6[ISI]

18 Hande A, Nagpal R. Intracranial malposition of nasogastric tube following transnasal transsphenoidal operation. Br J Neurosurg 1991; 5: 205–7[Medline]

19 Guerra B, Slade TL, Kelly PJ. Intracranial introduction of a nasogastric tube in a patient with a pituitary tumor. Surg Neurol 1979; 12: 135–6[ISI][Medline]