Nasotracheal suctioning (NTS) is commonly used in the intensive care unit (ICU) to remove accumulated saliva, blood, vomitus, pulmonary secretions, and other foreign material from the trachea and nasopharyngeal area that cannot be removed by the patient’s spontaneous cough, orotracheal suctioning, or other less invasive procedures. NTS aids in maintaining a patent airway, thereby facilitating oxygenation and ventilation and may prevent intubation for the removal of secretions.1
Current American Association for Respiratory Care clinical practice guidelines specify 2 absolute (epiglottitis or croup) and 10 relative contraindications to NTS, that is, occluded nasal passages, nasal bleeding, coagulopathy or bleeding disorder, laryngospasm, irritable airway, upper respiratory tract infection, tracheal surgery, gastric surgery with high anastomosis, myocardial infarction, bronchospasm, and acute head, facial, or neck injury.1 Although there are case reports of nasogastric tube and of nasoendotracheal tube placement in the intracranial cavity, often in patients with traumatic fractures of the face and the base of the skull, no published reports describe intracranial violation by an NTS catheter in a patient with a history of transsphenoidal surgery and facial or basilar skull fractures.2–4 We report a case of intracranial violation by an NTS catheter in a patient 25 days after transsphenoidal surgery for pituitary tumor.
The patient’s family gave written permission for the authors to publish the report.
The patient was a 37-year-old woman with a history of pituitary adenoma a year and a half earlier. She had returned to the neurosurgeon with new headaches and visual difficulties due to recurrence of pituitary adenoma and subsequently underwent repeat transsphenoidal resection of the 10-mm tumor. The operation was performed with a transnasal transsphenoidal approach. The operative report reveals that the patient’s posterior septum and vomer had previously been removed and all that remained was scar tissue over the anterior wall of the sphenoid sinus. The scar tissue and the pituitary adenoma were removed. On closure, her nasal septum was returned back to the midline, and incisions were closed with suture. No other tissue or plates were placed, and the left nostril was packed.
Her immediate postoperative course was complicated by the development of hemorrhage in the suprasellar region that extended into the third ventricle, causing hydrocephalus that required placement of a ventriculostomy tube. The patient had a prolonged stay in the neuro critical care unit because of multiple issues. These included: sepsis, development of deep vein thrombosis with subsequent severe vaginal hemorrhage in response to heparin, and, most notably, repeat tracheal extubations and reintubations to compensate for inadequate airway protection.
On postoperative day 25, the patient began having difficulty effectively maintaining her airway because of poor cough. In an effort to avoid tracheal reintubation, the nursing staff attempted orotracheal suctioning, which failed because she did not tolerate the suction catheter and would not follow commands to open her mouth. They then attempted NTS, which produced first thin and then bloody secretions. Shortly afterward, the patient was noted to have a decreased level of consciousness and required tracheal intubation. A computed tomography scan (Fig. 1) was obtained and showed pneumocephalus in the subdural space, ventricles, and prepontine cisterns. There was also a new area of parenchymal hemorrhage in the left parietal region that had the appearance of an attempted shunt placement, but no new shunt had been attempted. The only temporally related event identified was the use of the NTS catheter.
The patient’s trachea remained intubated and eventually a tracheotomy was placed for respiratory failure and a percutaneous endoscopic gastrostomy tube placed for malnutrition. She had resultant panhypopituitarism with subsequent hormone replacement and required long-term steroid replacement. Her stay in the neuro critical care unit was approximately 2.5 months. The patient’s baseline neurologic function at the time of dismissal to a long-term acute care facility was limited to raising the shoulders and moving the head side to side on command.
The patient continued to have medical complications associated with decreased neurologic function in the long-term facility. Her medical complications were numerous but included upper gastrointestinal bleeding, recurrent urinary tract infections, recurrent pneumonia, rectovaginal fistula with subsequent colostomy placement, deep vein thrombosis in the right lower extremity with inferior vena cava filter placement, and acute on chronic respiratory failure. There were 2 subsequent hospital admissions lasting about 1 week and approximately 2.5 months, respectively. She was eventually transferred to a long-term acute care facility in another city. She died approximately 1 year after her repeat transsphenoidal surgery.
The mechanical hazards associated with NTS may make it unsafe to attempt in a patient with recent transsphenoidal surgery because of the surgical compromise of the cranial vault. Nevertheless, there is little in the literature to guide us on the specific subject of NTS catheter use in this population. Commonly accepted contraindications to NTS do not reference transsphenoidal surgery. We found no published evidence of intracranial violation by an NTS catheter.
Evidence concerning similar mechanical hazards comes from >40 case reports of violations of the intracranial space by nasogastric suction catheters in patients with facial fractures.3 Another case report described inadvertent placement of a nasoendotracheal tube intracranially in a patient with undiagnosed cribriform plate agenesis.5 The report asserted that disruption of the skull base, whether by trauma or a previous surgical procedure, contraindicates nasoendotracheal or nasogastric tube placement.5 Last, 2 reports describe violation of the intracranial space by nasoendotracheal tube placement: 1 in a neonate with nasoendotracheal intubation,4 and 1 in a neurosurgery patient after a transsphenoidal operation with nasoendotracheal intubation.2 Together, the reports support the notion that nasal endotracheal intubation and nasogastric suction catheter placement are contraindicated in patients with facial fractures because of the potential for inadvertent placement of tubes in the brain secondary to occult fractures of the basilar skull, sphenoid sinus, or cribriform plate, as well as in patients with recent transsphenoidal surgery.2,3
NTS catheters are not as rigid as nasogastric or nasoendotracheal tubes. However, the present case illustrates that they are capable of violating the cranial vault if a bony defect is present. Although the present case is the first we are aware of in which an NTS catheter was intracranially placed, the combined evidence from the aforementioned reports leads us to propose that any bony defect in the basilar skull, sphenoid sinus, or cribriform plate, whether traumatic or surgical in origin, predisposes patients to intracranial misplacement of any nasally introduced tube (i.e., NTS catheters, nasogastric tubes, and nasoendotracheal tubes).
It may be argued that nasogastric tubes, nasoendotracheal tubes, and NTS catheters can be safely used at some point after facial fractures heal. The present case suggests that, for transsphenoidal surgery patients, the bony defect is still present for at least 25 days after surgery. Transsphenoidal surgery often leaves a permanent bony defect and, hence, may permanently predispose these patients to intracranial misplacement of any nasally introduced tube.2
Although intracranial tube placement is rare, its consequences are serious and include high mortality rates (50% or more), permanent disability, and litigation.5 Therefore, we propose adding transsphenoidal surgery to the list of contraindications to any nasal intubation. The present case also leads us to caution that when NTS appears to be the only viable option for airway clearance in a patient with recent transsphenoidal surgery, adequate precautions should be taken to ensure its safety, including imaging studies, fiberoptic visualization, or forgoing NTS altogether and orally intubating the patient’s trachea to maintain the airway.
Last, we suggest that until there are data to show the safety of placement of any nasally introduced tube at some point after transsphenoidal surgery, such precautions should be taken in all patients with any history of transsphenoidal surgery. At present, nasogastric tubes, NTS catheters, and nasoendotracheal tubes are frequently placed in anesthetized and comatose patients in the operating room and ICU whose history of facial or skull base fractures or transsphenoidal surgery is unknown.2 Increased awareness of the potential risks may improve policies and guidelines for the use of nasogastric and NTS catheters in ICU patients.