Case
Downloaded from www.ajronline.org by 113.76.189.9 on 11/05/15 from IP address 113.76.189.9. Copyright ARRS. For personal use only; all rights reserved
Perforation
of the of Left
Reports
Nasopharynx by Nasogastric Intubation Pleural Effusion and Pneumomediastinum PAUL
T.
SIEMERS1
AND
A case
of nasogastric tube perforation of the posterior producing a left pleural effusion and pneumomediastinum is reported. Findings which led to the correct diagnosis were the rapid appearance of a left pleural effusion simultaneous with the initiation of tube feedings, the intrathoracic location of the nasogastric tube, and demonstration of perforation of the posterior nasopharynx. Potentially hazardous intubation techniques are discussed.
quent vealed
nasopharynx
Most
radiologists
dwelling
are familiar
central
appearance mediate
venous
ment pleural
realize
position
the
calls
of the
tube
the
with
posterior
its subsequent
mediastinum
Case
without
other
her
abnormalities. and
continued
refusal
stituted.
A polyethylene
left
naris
with
the
posterior
placed
some
through
eat,
initial
the
tube
while
sound
nasogastric
the
passed
in advancing
the
the
tube
its rigidity.
and
was
were
tube
inserted,
then
auscultated.
fluid
was
sions, in-
it was injected
char-
examination revealed dullness of the left hemithorax decreased breath sounds. A thoracic roentgenogram showed a large left pleural effusion and pneumomediastinum (fig. 1 ). The distal tip of the nasogastric tube was at the level of the gastroesophageal junction. Gastrografin instillation through the nasoPhysical
tube
revealed
extravasation
posterior
into
the
left pleural
space
(fig.
in
the
midline
(fig.
3)
and
had
1
Department
Am
of
California
J Roentgenol
Radiology,
921 61 1 27 : 341
University .
Address
-343,
Hospital. reprint
1976
requests
University
of California at the
and
are
organ
unaware
including
laceration, in 60%
of passage
of other of
5].
of
case,
advancement to
by placing
341
Veterans
Administration
been
described
in the
may
esophageal However,
be
past
confused
diverticulum, it has a charac-
appearance with barium filling an channel posterior to the esophagus. of
increase
the
the
it in ice prior of
Administration Hospital.
in
pseudo-
than 12 cases of traunasopharynx and upper
pseudodiverticulum
likelihood
of naso-
phanyngeal
formation tube
rigidity
into
the
of
the
to insertion,
producing
Hospital.
pre-
pleural
nasogastnic
as in this
injury.
3350
was left
This
should be discouraged. The fallacy of assessing tube position by auscultation of the epigastrium injected into the tubing is obvious. Air bubbling and
of
nasopharynx
perforation
esophageal atresia, of the esophagus.
noentgenographic elongated false
the
have
Traumatic
by
Diego,
those
as a result cases
posterior
cause
in newborns
present
Veterans
postof
Nasogastric of these le-
and
reported
the
is a recognized
In the
at San
as
to trauma
injury,
mucosal perforation
injury
perforation
[9-1
increase
esopha-
of prior instrumentation. for a significant number
vented
tubing
dissected
to R. T. Reinke
this
space. Attempts
2),
along the posterior mediastinum (fig. 4), entering the left pleural space. Closed chest tube drainage, parenteral antibiotics, and vigorous pulmonary toilet led to an uneventful recovery. Subse-
San Diego,
adults,
teristic irregular
of the esophagus or stomach. Oral ingestion that the nasogastric tube had perforated the
nasopharynx
we tube
clinically with and duplication
with
lower
tubing.
esophagus
developed.
perfora-
and Kessler [8]. revealed poste-
esophageal acute
as an acute
gastric
5 years
to
in-
Such
with predisposing has been reported
Wolff autopsies
diverticulum in the neonate. More matic perforation of the posterior
as reassur-
and
both
by
upper
with a history accounted
While
the
through
The
taken
ulceration,
freeso-
endotracheal [2-6].
upper-middle
documented of consecutive and
is a
is more
nasojejunal intubation [7]. of the posterior nasopharynx
nicely series
the indwelling
biopsy,
have been associated Duodenal perforation
hemorrhage,
patients intubation
which
tamponade
in the
instru-
esophagogastroscopy,
esophageal
occurred
pharyngeal
cnicoid
of
resis,
without visualization of gastrografin showed
and some pathology.
submucosal
electro-
of its intragastric location. Transtubal feedings of a puree were begun. Within 12 hr, left chest pain, dyspnea, diapho-
gastric
have
gus, local
nor
of
increasing
intubation
perforation,
esophageal
is
therapeutic
Nasogastric
complication
tions
esophagus and
esophagus.
a complication of The susceptibility
left
ance broth
fever
esophageal
dilatation,
through
Air was
was
through
of
phageal
Because
feedings
was
epigastrium
of air bubbling
normal.
tube
tube
Before
to increase
studies,
were
difficulty
nasopharynx.
in ice water
acteristic
laboratory
nasogastric
rare
has been Their large
roentgenogram to
the
tubation,
Report
Routine
thoracic
of
cause
the
diagnostic
mentation
im-
pneunaso-
of
aggressive
[1].
A 58-year-old white woman was admitted to University Hospital for inanition subsequent to a depression-induced refusal to eat. Past medical history was normal except for tonsillectomy and adenoidectomy in childhood and a rhinoplasty following trauma in 1954. Physical examination revealed a debilitated, dehydrated woman cardiogram,
perforation
more
a
the
nasopharynx retissue. No local
noted.
latrogenic with
advanceinto
examination of the posterior site with adjacent granulation
Discussion
rapid
cause of pleural effusion and perforation of the posterior
endoscopic a puncture was
Cause
REINKE1
quently
for
catheter
T.
pathology
of in-
that
automatically
of the distal
by a nasogastric through space.
complications
and
effusion
We report an unusual momediastinum-a pharynx
the
catheters
of a pleural assessment
with
ROBERT
: A Rare
La Jolla
case,
practice
nasogastnic while air is within the Village
Drive.
Downloaded from www.ajronline.org by 113.76.189.9 on 11/05/15 from IP address 113.76.189.9. Copyright ARRS. For personal use only; all rights reserved
342
CASE
.i.c
‘.::,
:,:.T
..
.
.-t,’:.
:. , .
Fig. strating effusion
1 .-AP rapid
supine film of chest appearance (previously
REPORTS
;
.
.
1%i
.
after initiation normal chest
-.. ‘
of tube feedings demonfilm) of large left pleural
and pneumomediastinum.
Fig. 3.-Lateral spot film of nasopharynx location of nasogastric tube. Arrow shows
The nosis the
roentgenognaphic in this
case
are
gastroesophageal
tube
feeding.
geal
on
that
with
central
wary
of a perforation
mediastinum nasogastnic
the
views,
nasopharynx
findings
which
suggest
location
of the
nasogastnic
(but
accumulating simultaneous
While
oblique
)
junction
and (2) a rapidly pneumomediastinum
the
(1
demonstrating retropharyngeal posterior wall of pharynx.
venous develops
not
left
in the
tube
was
it was
only
the
lateral
the
site
of
catheters, when
the
pleural
in the
diagtube
presence
and of
extraesophaspot
film
perforation.
radiologist
effusion
at
stomach),
pleural effusion with the initiation
nasogastric showed
the
should
and/or of an
of As be
pneumo-
intnathoracic
tube. REFERENCES
Fig.
2.-AP
spot
gastroesophageal pleural
film of tip of junction with
nasogastric extravasation
tube of
showing it gastrografin
in
region
into
of left
space.
pleural stained assessing
space gastric tube
produces contents placement.
a similar remains
sound. a
The superior
return
of bile-
method
of
1 . Oakes DD, Wilson RE : Malposition of a subclavian line. JAMA 233:532-533, 1975 2. Johnson J, Schwegman CW, MacVaugh H Ill : Early esophagogastrostomy in the treatment of iatnogenic perforation of the distal esophagus. J Thorac Cardiovasc Surg 55 : 24-29, 1968 3. Mathewson C, Dozier WE, Hamill JP, Smith M : Clinical ex-
CASE
343
REPORTS
I ,‘
4. 5.
periences
with
257-266,
1962
Rabinovich agus. Arch Wichern
S. Smith Otolaryngo! WA
Downloaded from www.ajronline.org by 113.76.189.9 on 11/05/15 from IP address 113.76.189.9. Copyright ARRS. For personal use only; all rights reserved
534-536. 6.
perforation
of the
IM,
esophagus.
McCabe
BF : Rupture
85 : 41 0-41
: Perforation
Am
of the
J Surg of the
1 04: esoph-
5, 1 967
esophagus.
Am
J Surg
1 19:
1 970
Wolloch
V. Zer M, Dintsman
M, Tiqva
P : latrogenic
perforations
of the esophagus. Arch Surg 1 08 : 357-360, 1 974 7. BoroS SJ, Reynolds JW : Duodenal perforation : a complication of neonatal nasojejunal feeding. J Pediatr 85 :107-108, 1974 8.
Wolff
AP,
cervical
Kessler
S : latrogenic
esophagus
:
an
Laryngol 82 :778-883, 9.
Armstrong
AG,
Wolfe
AD,
esophagus 1 0.
Astley
in the A, Roberts
De
Espinosa
EF,
newborn
baby. H, De
hypopharynx Ann
Stanford
: Traumatic
Oto!
and Rhino!
BrJ
infant.
Radio!
Paredes
W,
Takamoto
pseudodiverticulum
KD : Intubation
in the newborn 11.
JW
to the study.
1973
Lindberg
Dietz
injury
autopsy
Surgery
67 : 844-846,
perforation
of the
43 : 21 9-222,
AM, of
the 1 970
esophagus
1970
CG : Traumatic
perforation
of the
9 : 247-248, 1974 1 2. Ducharme JC, Bertrand A, Devie J : Perforation of the pharynx in the newborn : a condition mimicking esophageal atresia. Can Med Assoc J 1 04 : 78, 1 971 pharynx
1 3.
Ekl#{246}f0,
esophagus 1969 14.
Girdany
in a newborn
baby.
L#{246}hrG, Okmian in the neonate. BA,
diverticulums
J Pediatr
L : Submucosal perforation of the Acta Radio! (Stockh) 8 : 1 87-1 92,
Sieber
WK,
of
pharynx
the
Surg
Osman
MZ:
Traumatic
in
newborn
infants.
280 : 237-240, 1 969 1 5. Gwinn JL Lee FA : Radiological
pseudoN
Engi
Med
,
,
.
.,.-“,
tube posterior of gastrografin
me Ljft anterior o..,.que to esophagus in posterior into left pleural space.
film of ciest mediastinum.
showing Note
nasc,u....... extravasation
.c
diverticulum 1974
of
the
pharynx.
case of the month Am
J
Dis
Child
: pseudo-
1 21 : 329-330,
J
Downloaded from www.ajronline.org by 113.76.189.9 on 11/05/15 from IP address 113.76.189.9. Copyright ARRS. For personal use only; all rights reserved
Perforation
of the of Left
Reports
Nasopharynx by Nasogastric Intubation Pleural Effusion and Pneumomediastinum PAUL
T.
SIEMERS1
AND
A case
of nasogastric tube perforation of the posterior producing a left pleural effusion and pneumomediastinum is reported. Findings which led to the correct diagnosis were the rapid appearance of a left pleural effusion simultaneous with the initiation of tube feedings, the intrathoracic location of the nasogastric tube, and demonstration of perforation of the posterior nasopharynx. Potentially hazardous intubation techniques are discussed.
quent vealed
nasopharynx
Most
radiologists
dwelling
are familiar
central
appearance mediate
venous
ment pleural
realize
position
the
calls
of the
tube
the
with
posterior
its subsequent
mediastinum
Case
without
other
her
abnormalities. and
continued
refusal
stituted.
A polyethylene
left
naris
with
the
posterior
placed
some
through
eat,
initial
the
tube
while
sound
nasogastric
the
passed
in advancing
the
the
tube
its rigidity.
and
was
were
tube
inserted,
then
auscultated.
fluid
was
sions, in-
it was injected
char-
examination revealed dullness of the left hemithorax decreased breath sounds. A thoracic roentgenogram showed a large left pleural effusion and pneumomediastinum (fig. 1 ). The distal tip of the nasogastric tube was at the level of the gastroesophageal junction. Gastrografin instillation through the nasoPhysical
tube
revealed
extravasation
posterior
into
the
left pleural
space
(fig.
in
the
midline
(fig.
3)
and
had
1
Department
Am
of
California
J Roentgenol
Radiology,
921 61 1 27 : 341
University .
Address
-343,
Hospital. reprint
1976
requests
University
of California at the
and
are
organ
unaware
including
laceration, in 60%
of passage
of other of
5].
of
case,
advancement to
by placing
341
Veterans
Administration
been
described
in the
may
esophageal However,
be
past
confused
diverticulum, it has a charac-
appearance with barium filling an channel posterior to the esophagus. of
increase
the
the
it in ice prior of
Administration Hospital.
in
pseudo-
than 12 cases of traunasopharynx and upper
pseudodiverticulum
likelihood
of naso-
phanyngeal
formation tube
rigidity
into
the
of
the
to insertion,
producing
Hospital.
pre-
pleural
nasogastnic
as in this
injury.
3350
was left
This
should be discouraged. The fallacy of assessing tube position by auscultation of the epigastrium injected into the tubing is obvious. Air bubbling and
of
nasopharynx
perforation
esophageal atresia, of the esophagus.
noentgenographic elongated false
the
have
Traumatic
by
Diego,
those
as a result cases
posterior
cause
in newborns
present
Veterans
postof
Nasogastric of these le-
and
reported
the
is a recognized
In the
at San
as
to trauma
injury,
mucosal perforation
injury
perforation
[9-1
increase
esopha-
of prior instrumentation. for a significant number
vented
tubing
dissected
to R. T. Reinke
this
space. Attempts
2),
along the posterior mediastinum (fig. 4), entering the left pleural space. Closed chest tube drainage, parenteral antibiotics, and vigorous pulmonary toilet led to an uneventful recovery. Subse-
San Diego,
adults,
teristic irregular
of the esophagus or stomach. Oral ingestion that the nasogastric tube had perforated the
nasopharynx
we tube
clinically with and duplication
with
lower
tubing.
esophagus
developed.
perfora-
and Kessler [8]. revealed poste-
esophageal acute
as an acute
gastric
5 years
to
in-
Such
with predisposing has been reported
Wolff autopsies
diverticulum in the neonate. More matic perforation of the posterior
as reassur-
and
both
by
upper
with a history accounted
While
the
through
The
taken
ulceration,
freeso-
endotracheal [2-6].
upper-middle
documented of consecutive and
is a
is more
nasojejunal intubation [7]. of the posterior nasopharynx
nicely series
the indwelling
biopsy,
have been associated Duodenal perforation
hemorrhage,
patients intubation
which
tamponade
in the
instru-
esophagogastroscopy,
esophageal
occurred
pharyngeal
cnicoid
of
resis,
without visualization of gastrografin showed
and some pathology.
submucosal
electro-
of its intragastric location. Transtubal feedings of a puree were begun. Within 12 hr, left chest pain, dyspnea, diapho-
gastric
have
gus, local
nor
of
increasing
intubation
perforation,
esophageal
is
therapeutic
Nasogastric
complication
tions
esophagus and
esophagus.
a complication of The susceptibility
left
ance broth
fever
esophageal
dilatation,
through
Air was
was
through
of
phageal
Because
feedings
was
epigastrium
of air bubbling
normal.
tube
tube
Before
to increase
studies,
were
difficulty
nasopharynx.
in ice water
acteristic
laboratory
nasogastric
rare
has been Their large
roentgenogram to
the
tubation,
Report
Routine
thoracic
of
cause
the
diagnostic
mentation
im-
pneunaso-
of
aggressive
[1].
A 58-year-old white woman was admitted to University Hospital for inanition subsequent to a depression-induced refusal to eat. Past medical history was normal except for tonsillectomy and adenoidectomy in childhood and a rhinoplasty following trauma in 1954. Physical examination revealed a debilitated, dehydrated woman cardiogram,
perforation
more
a
the
nasopharynx retissue. No local
noted.
latrogenic with
advanceinto
examination of the posterior site with adjacent granulation
Discussion
rapid
cause of pleural effusion and perforation of the posterior
endoscopic a puncture was
Cause
REINKE1
quently
for
catheter
T.
pathology
of in-
that
automatically
of the distal
by a nasogastric through space.
complications
and
effusion
We report an unusual momediastinum-a pharynx
the
catheters
of a pleural assessment
with
ROBERT
: A Rare
La Jolla
case,
practice
nasogastnic while air is within the Village
Drive.
Downloaded from www.ajronline.org by 113.76.189.9 on 11/05/15 from IP address 113.76.189.9. Copyright ARRS. For personal use only; all rights reserved
342
CASE
.i.c
‘.::,
:,:.T
..
.
.-t,’:.
:. , .
Fig. strating effusion
1 .-AP rapid
supine film of chest appearance (previously
REPORTS
;
.
.
1%i
.
after initiation normal chest
-.. ‘
of tube feedings demonfilm) of large left pleural
and pneumomediastinum.
Fig. 3.-Lateral spot film of nasopharynx location of nasogastric tube. Arrow shows
The nosis the
roentgenognaphic in this
case
are
gastroesophageal
tube
feeding.
geal
on
that
with
central
wary
of a perforation
mediastinum nasogastnic
the
views,
nasopharynx
findings
which
suggest
location
of the
nasogastnic
(but
accumulating simultaneous
While
oblique
)
junction
and (2) a rapidly pneumomediastinum
the
(1
demonstrating retropharyngeal posterior wall of pharynx.
venous develops
not
left
in the
tube
was
it was
only
the
lateral
the
site
of
catheters, when
the
pleural
in the
diagtube
presence
and of
extraesophaspot
film
perforation.
radiologist
effusion
at
stomach),
pleural effusion with the initiation
nasogastric showed
the
should
and/or of an
of As be
pneumo-
intnathoracic
tube. REFERENCES
Fig.
2.-AP
spot
gastroesophageal pleural
film of tip of junction with
nasogastric extravasation
tube of
showing it gastrografin
in
region
into
of left
space.
pleural stained assessing
space gastric tube
produces contents placement.
a similar remains
sound. a
The superior
return
of bile-
method
of
1 . Oakes DD, Wilson RE : Malposition of a subclavian line. JAMA 233:532-533, 1975 2. Johnson J, Schwegman CW, MacVaugh H Ill : Early esophagogastrostomy in the treatment of iatnogenic perforation of the distal esophagus. J Thorac Cardiovasc Surg 55 : 24-29, 1968 3. Mathewson C, Dozier WE, Hamill JP, Smith M : Clinical ex-
CASE
343
REPORTS
I ,‘
4. 5.
periences
with
257-266,
1962
Rabinovich agus. Arch Wichern
S. Smith Otolaryngo! WA
Downloaded from www.ajronline.org by 113.76.189.9 on 11/05/15 from IP address 113.76.189.9. Copyright ARRS. For personal use only; all rights reserved
534-536. 6.
perforation
of the
IM,
esophagus.
McCabe
BF : Rupture
85 : 41 0-41
: Perforation
Am
of the
J Surg of the
1 04: esoph-
5, 1 967
esophagus.
Am
J Surg
1 19:
1 970
Wolloch
V. Zer M, Dintsman
M, Tiqva
P : latrogenic
perforations
of the esophagus. Arch Surg 1 08 : 357-360, 1 974 7. BoroS SJ, Reynolds JW : Duodenal perforation : a complication of neonatal nasojejunal feeding. J Pediatr 85 :107-108, 1974 8.
Wolff
AP,
cervical
Kessler
S : latrogenic
esophagus
:
an
Laryngol 82 :778-883, 9.
Armstrong
AG,
Wolfe
AD,
esophagus 1 0.
Astley
in the A, Roberts
De
Espinosa
EF,
newborn
baby. H, De
hypopharynx Ann
Stanford
: Traumatic
Oto!
and Rhino!
BrJ
infant.
Radio!
Paredes
W,
Takamoto
pseudodiverticulum
KD : Intubation
in the newborn 11.
JW
to the study.
1973
Lindberg
Dietz
injury
autopsy
Surgery
67 : 844-846,
perforation
of the
43 : 21 9-222,
AM, of
the 1 970
esophagus
1970
CG : Traumatic
perforation
of the
9 : 247-248, 1974 1 2. Ducharme JC, Bertrand A, Devie J : Perforation of the pharynx in the newborn : a condition mimicking esophageal atresia. Can Med Assoc J 1 04 : 78, 1 971 pharynx
1 3.
Ekl#{246}f0,
esophagus 1969 14.
Girdany
in a newborn
baby.
L#{246}hrG, Okmian in the neonate. BA,
diverticulums
J Pediatr
L : Submucosal perforation of the Acta Radio! (Stockh) 8 : 1 87-1 92,
Sieber
WK,
of
pharynx
the
Surg
Osman
MZ:
Traumatic
in
newborn
infants.
280 : 237-240, 1 969 1 5. Gwinn JL Lee FA : Radiological
pseudoN
Engi
Med
,
,
.
.,.-“,
tube posterior of gastrografin
me Ljft anterior o..,.que to esophagus in posterior into left pleural space.
film of ciest mediastinum.
showing Note
nasc,u....... extravasation
.c
diverticulum 1974
of
the
pharynx.
case of the month Am
J
Dis
Child
: pseudo-
1 21 : 329-330,
J
