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LETTERS TO EDITOR
Year : 2019  |  Volume : 20  |  Issue : 1  |  Page : 58-60
 

Iatrogenic perforation of the parapharyngeal wall after nasogastric tube insertion in an anesthetized patient


1 Department of Anaesthesiology, Al-Ahsa Hospital, Ministry of Health, Hofuf, Kingdom of Saudi Arabia
2 Department of Anesthesiology, Al-Azhar University, Saudi Ministry of Health, Al-Ahsa Hospital, Cairo, Egypt

Date of Web Publication6-May-2019

Correspondence Address:
Dr. Mohamed Mustafa Alazab
Department of Anesthesiology, Al-Azhar University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_16_19

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How to cite this article:
Elagizy MM, Naguib AH, Alazab MM. Iatrogenic perforation of the parapharyngeal wall after nasogastric tube insertion in an anesthetized patient. Indian Anaesth Forum 2019;20:58-60

How to cite this URL:
Elagizy MM, Naguib AH, Alazab MM. Iatrogenic perforation of the parapharyngeal wall after nasogastric tube insertion in an anesthetized patient. Indian Anaesth Forum [serial online] 2019 [cited 2019 Nov 13];20:58-60. Available from: http://www.theiaforum.org/text.asp?2019/20/1/58/257676




Sir,

Nasogastric tube (NGT) is frequently inserted to evacuate the gastric contents and to deflate the stomach during laparoscopic surgeries for clearer view and to avoid gastric perforation. Improper NGT insertion may be associated with complications such as aspiration pneumonia, nasal mucosal and pharyngeal injury, esophageal and enteric organs perforation, bronchial placement and vascular penetration.[1],[2] In anesthetized patients, the NGT placement is often difficult, and multiple and forceful insertion attempts can result in unanticipated trauma to the pharyngeal wall.[3] We present a case of iatrogenic parapharyngeal abscess in an elective laparoscopic cholecystectomy, which developed after several attempts of NGT insertion.

A 57-year-old female obese, diabetic, hypertensive patient was scheduled for laparoscopic cholecystectomy. An NGT insertion was requested for gastric decompression. When nasal insertion failed after several attempts, the tube was inserted orally.

Eight days postoperatively, she came to the emergency department in confused state with fever (40°C), tachycardia (130 bpm), low blood pressure (80/50), respiratory distress, and left neck fullness. This required immediate intubation during which oropharyngeal swelling with left-shifted edematous uvula was noticed. Intravenous crystalloids and inotropes were started, and the patient transferred to the intensive care unit. The patient was put on mechanical ventilator and was sedated with fentanyl and midazolam infusion. Blood samples for routine and microbiology, computed tomographic (CT) scan, and X-ray neck were done and empirical antibiotics were started (imipenem-cilastatin and vancomycin). X-ray cervical spine showed massive swelling of the soft tissues of the left side of the neck and endotracheal tube shifted to the right side [Figure 1].
Figure 1: X-ray cervical spine anterior-posterior showing massive swelling of the soft tissues of the left side of the neck and endotracheal tube shifted to the right side of the neck

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CT scan revealed “a large left parapharyngeal and paratracheal heterogeneous soft tissue mass lesion with central degenerative cystic foci probably inflammatory lesion likely parapharyngeal abscess which extends poster-laterally to involve the stylomandibular tunnel and retrostyloid space with compression effect on the airway causing deviation of the endotracheal tube to the right side” [Figure 2] and [Figure 3].
Figure 2: Large left parapharyngeal and paratracheal heterogeneous soft tissue mass lesion with multiple central degenerative cystic lesion probably inflammatory lesion, red dotted

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Figure 3: Parapharyngeal abscess which extends poster-laterally to involve the stylomandibular tunnel and retrostyloid space with compression effect on the airway causing deviation of the endotracheal tube to the right side, red dotted

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Incision and drainage of the abscess was done under general anesthesia. On the 3rd day, the general condition and the vital signs started to improve. On the 6th day, the patient's general conditions and the vital signs stabilized and parapharyngeal abscess resolved, and only mild soft tissue inflammation remained.

On subsequent days, the patient was weaned off the mechanical ventilator and was transferred to the medical ward for further management.

Anesthesiologists should be aware of the possible complications of NGT insertion in an intubated patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bautista EM. Complications of nasogastric tube insertion. Chest 1988;93:1119-20.  Back to cited text no. 1
    
2.
Pillai JB, Vegas A, Brister S. Thoracic complications of nasogastric tube: Review of safe practice. Interact Cardiovasc Thorac Surg 2005;4:429-33.  Back to cited text no. 2
    
3.
Tsai YF, Luo CF, Illias A, Lin CC, Yu HP. Nasogastric tube insertion in anesthetized and intubated patients: A new and reliable method. BMC Gastroenterol 2012;12:99.  Back to cited text no. 3
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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