Iatrogenic perforation of the lamina cribrosa by nasogastric tube in an infant

Combined Open Surgical and Endoscopic Approach for Management of a Meningoencephalocele After Iatrogenic Perforation of the Anterior Skull Base in a Young Infant

Traumatic iatrogenic perforation of the anterior skull base is a rare complication following endonasal intubation in preterm infants. Subsequent meningoencephaloceles with concomitant cerebrospinal fluid (CSF) fistulas bear the risk of severe complications, therefore early diagnosis and closure of the skull defect are crucial. However, there is no consensus on the management of such cases of meningoencephaloceles. This case report presents a sophisticated approach of open brain surgery in combination with endonasal endoscopy. A 15-month-old girl presented with a meningoencephalocele and a CSF fistula due to iatrogenic perforation of the left anterior skull base during attempted endonasal intubation after birth. Difficult nasal breathing and an increasing diameter of the skull base defect on imaging controls indicated surgical management. Close multidisciplinary collaboration was essential for diagnosis and decision upon treatment. Open neurosurgical resection and CSF fistula closure combined with endonasal endoscopic removal of the excised meningoencephalocele was performed. Our case report shows that this combined open surgical and endonasal endoscopic approach is a safe procedure in favor of the postoperative outcome and follow-up of the patient.

Iatrogenic meningoencephalocele after traumatic perforation of the cribriform plate during nasal intubation of a preterm infant

Traumatic iatrogenic meningoencephaloceles infants are rare and there is no consensus on management in the literature. This article presents a case of a meningoencephalocele diagnosed 15 months after a traumatic perforation of the cribriform plate due to a difficult intubation of a preterm infant that was treated by an endoscopic endonasal surgery. A close collaboration between pediatricians and ENT surgeons appears essential for early diagnosis and management. Endoscopic endonasal approach for meningoencephalocele management has several advantages and is a safe procedure when performed by an experienced surgeon.

A rare complication of Epistats

We report a 53-year-old man who sustained severe facial and base of skull fractures. At the scene of his accident he had Epistats (Medtronic Sofamor Danek, Memphis, TN, USA) placed for control of his severe nasal haemorrhage, subsequently resulting in the migration of one Epistat into the anterior cranial fossa. There are numerous reports of inadvertent intracranial placement of medical equipment, predominantly in association with complex facial and skull trauma. Other factors that can predispose to aberrant location include previous anterior cranial base surgery and lesions affecting structures in that area.

Traumatic perforation of the lamina cribrosa during nasal intubation of a preterm infant

Traumatic perforation of the lamina cribrosa and penetration of the brain occurred during nasotracheal intubation of a preterm infant requiring resuscitation. This rare complication is specifically associated with the nasal route of intubation. The complication resulted in significant morbidity. The infant developed an extensive intracranial hemorrhage and posthemorrhagic hydrocephalus that required ventricular drainage. We recommend that nasotracheal intubation be performed with utmost care. We confirm Cameron and Lupton's recommendation of using a small feeding tube over which to slide the endotracheal tube. Despite extensive iatrogenic damage, the patient's neurodevelopmental follow-up at 2 years 9 months appeared relatively mild.

Traumatic epistaxis: Skull base defects, intracranial complications and neurosurgical considerations

INTRODUCTION

Endonasal procedures may be necessary during management of craniofacial trauma. When a skull base fracture is present, these procedures carry a high risk of violating the cranial vault and causing brain injury or central nervous system infection.

PRESENTATION OF CASE

A 52-year-old bicyclist was hit by an automobile at high speed. He sustained extensive maxillofacial fractures, including frontal and sphenoid sinus fractures (Fig. 1). He presented to the emergency room with brisk nasopharyngeal hemorrhage, and was intubated for airway protection. He underwent emergent stabilization of his nasal epistaxis by placement of a Foley catheter in his left nare and tamponade with the Foley balloon. A six-vessel angiogram showed no evidence of arterial dissection or laceration. Imaging revealed inadvertent insertion of the Foley catheter and deployment of the balloon in the frontal lobe (Fig. 2). The balloon was subsequently deflated and the Foley catheter removed. The patient underwent bifrontal craniotomy for dural repair of CSF leak. He also had placement of a ventriculoperitoneal shunt for development of post-traumatic hydrocephalus. Although the hospital course was a prolonged one, he did make a good neurological recovery.

DISCUSSION

The authors review the literature involving violation of the intracranial compartment with medical devices in the settings of craniofacial trauma.

CONCLUSION

Caution should be exercised while performing any endonasal procedure in the settings of trauma where disruption of the anterior cranial base is possible.

Inadvertent intracranial insertion of a soft rubber tube in a patient with Treacher-Collins syndrome: case report and review of literature

CASE REPORT

An inadvertent insertion of a soft rubber tube into the intracranial compartment in a patient with Treacher-Collins syndrome is reported. The neonate was delivered vaginally at 34 weeks gestation, had bilateral choanal atresia and presented with apnea at birth. An emergency orotracheal intubation was performed, and ventilatory support was instituted. Computed tomography scan of the facial bones showed a bilateral bony choanal atresia, with a thick posterior nasal septum, and complete absence of maxillary sinuses, external auditory canal, middle ear and ossicles, and roof of ethmoid bone. There was a central cleft in the frontoethmoidal area. The inner ear and the semicircular canals were present. The patient underwent successful transpalatal repair with nasal stenting. During surgery, two unsuccessful attempts to negotiate a soft rubber tube through the occluded choana were made. Postoperative magnetic resonance imaging revealed a linear hemorrhagic tract created by the soft rubber tube coursing through the anteroinferior basal frontal lobe, thalamus, basal ganglia and terminating in the occipital lobe. The patient developed bacterial meningitis, communicating hydrocephalus followed by cerebrospinal fluid rhinorrhea. A transcranial repair of the anterior cranial fossa was performed followed by ventriculoperitoneal shunt insertion. Subsequently, he underwent shunt revision for suspected shunt malfunction and developed peritoneal abscess for which the shunt was exteriorized and later removed. An endoscopic third ventriculostomy was performed, and the patient is recovering well.

DISCUSSION

The potential implications of an inadvertent foreign body penetration into the intracranial compartment in such a rare event are discussed and the relevant literature is briefly reviewed.

Risk management, or just a different risk?

BACKGROUND

National reporting of adverse incidents has resulted in a number of clinical alerts being issued. Despite a lack of evidence, these alerts are often accompanied by a mandatory requirement to alter practice. There is likely to be clinician resistance to such a method of change management, particularly where evidence of safety is missing.

AIM

To determine the level of implementation within neonatal units of an alert requiring the change from litmus to pH paper to test nasogastric tube position.

METHOD

A questionnaire sent to all neonatal units in the United Kingdom with more than 12 cots.

RESULTS

From the 207 questionnaires sent, there were 165 (80%) responses. Fifty five percent of units were still using litmus. All continued to use supplementary tests not recommended in best practice statements issued at the time of the alert. There was considerable variation in the pH value at which it was considered safe to feed.

CONCLUSIONS

Nine months after the alert, more than half the units had not changed to pH paper, and supplementary methods of testing were still being used. The wide range of pH values highlights the uncertainty about the "normal" gastric pH in the newborn. The evidence that, in neonatal units, changing to pH paper is safer than the long established use of litmus is lacking. Recommendations for change in practice must be based on good information and not seen just as a "knee jerk" response to adverse incidents.

[Accidental intracerebral penetration of a nasal hemostatic probe]

We report a case of inadvertent intracerebral introduction of a haemostatic device (Brighton tube) inserted into a nasal cavity for control of epistaxis in a patient with major craniofacial trauma. This complication remained unrecognized in the unconscious patient until the subsequent CT-scan control. In unconscious patients with a major facial trauma, intranasal haemostatic probes should be inserted under direct visual control by a ENT specialist and their position checked by digital palpation of the inflated cuffs behind the soft palate.

Intracranial insertion of a nasogastric tube in a case of homicidal head trauma

A case of accidental intracranial penetration of a 29-cm-long portion of nasogastric tube (NGT) in a 27-year-old female victim of a severe homicidal skull and brain trauma is reported. Accidental penetration of the NGT occurred through a large fracture of the ethmoid lamina cribrosa. In addition to a systematic review of previously reported cases, circumstantial data, clinical aspects, and autopsy data have been analyzed to draw medicolegal considerations concerning the connection between death and insertion of an NGT, which may also contribute to the ascertaining of any possible professional responsibility of medical staff, in a case fraught with numerous legal complications.

Examining the safety of nasogastric tube placement after endoscopic sinus surgery

Several cases of intracranial injury during the placement of nasogastric tubes have been reported, usually in the setting of anterior skull base fractures. The fovea ethmoidalis and sphenoid sinus are often exposed after endoscopic sinus surgery, so that these structures are potentially placed in the line of contact during nasogastric tube placement. In order to evaluate the ability of the fovea ethmoidalis and roof of the sphenoid sinus to withstand penetration from possible contact during nasogastric tube placement, 12 fresh cadaver heads were studied. After complete endoscopic ethmoidectomy and wide sphenoidotomy, standard 18F and 16F nasogastric tubes were inserted to produce deliberate direct contact with both the fovea ethmoidalis and the sphenoid sinus roof. No penetrations of the fovea occurred in 20 specimen sides with the 18F tube; penetration did occur with the 16F tube in 1 of 13 sides (7.7%). With respect to the sphenoid sinus, no intracranial penetrations occurred in 16 and 11 sides for the 18F and 16F tubes, respectively. The sphenoid sinus was easily entered even in the presence of an intact middle turbinate. These data suggest that although intracranial penetration during nasogastric intubation after endoscopic sinus surgery is an unlikely event, there is a non-negligible risk of such injury. Nasogastric intubation should be performed with caution in patients with a history of sinus surgery.

Inadvertent intracranial insertion of a nasogastric tube in a non-trauma patient

Complications following nasogastric intubation in patients with basal skull fractures are well documented. This report is of a rare cause of inadvertent intracranial placement of a nasogastric (NG) tube in a non-trauma patient. The patient subsequently died. The use of NG tubes, their place in airway management, and lessons to be learned from this case are discussed.

An unusual cause of altered mental status

A case of altered mental status secondary to pneumocephalus as a complication of sinus surgery is presented. The pathophysiology, clinical presentation, diagnosis, and management of pneumocephalus are discussed.