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Inadvertent placement of a nasogastric tube following traumatic nasal tube intubation
  1. Timothy Manzie1,
  2. Philip Chia2,
  3. Sivakumar Gananadha2 and
  4. Alexander Bobinskas1
  1. 1Oral and Maxillofacial Surgery, Canberra Hospital, Canberra, Australian Capital Territory, Australia
  2. 2General Surgery, Canberra Hospital, Canberra, Australian Capital Territory, Australia
  1. Correspondence to Timothy Manzie; tmanzie{at}


Adequate nutrition is necessary in head and neck surgery. Enteral feeding via a nasogastric tube is often required due to the altered anatomy and to allow sufficient intraoral healing. Insertion of a nasogastric tube is commonly performed without complication and confirmation of its position by a number of different methods. Incorrect positioning can cause significant morbidity with associated mortality. This case report describes the inadvertent placement of a nasogastric tube in a patient with a mandibular squamous cell carcinoma, into the abdominal cavity following a failed traumatic nasal tube intubation. Chest radiography and auscultation failed to identify the abnormal position with subsequent commencement of feeds for a number of days. Following a laporotomy and insertion of abdominal drains, the patient recovered and was discharged from hospital. To prevent recurrence, it is suggested that direct laryngoscopy or direct visualisation of the upper aspect be performed.

  • mouth
  • oral and maxillofacial surgery
  • general surgery
  • parenteral / enteral feeding
  • head and neck cancer

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  • Contributors All authors (TM, PC, SG and AB) have been involved in the care of the patient. All authors have had the opportunity to review and comment on the submitted manuscript. TM, PC and AB were involved in planning the initial draft. TM and PC were involved in the writing of the first draft. PC, SG and AB reviewed the draft manuscripts and provided editorial advice. TM and SG provided the images. TM, PC, SG and AB have reviewed the final manuscript. No authors have any conflict to declare.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.