Case report: intracranial placement of a nasotracheal tube in a patient with Goldenhar syndrome associated with cribriform plate agenesis.
We describe a case of inadvertent intracranial placement of a nasotracheal tube in a patient with an undiagnosed major congenital cranial anomaly (a variant of Goldenhar syndrome, which included absence of the cribriform plate). We believe that this is the first reported case in which this complication arose as a result of a congenital abnormality rather than traumatic or iatrogenic disruption of the skull base. We conclude that patients with known craniofacial abnormalities or associated syndromes scheduled for procedures involving planned nasotracheal intubation or nasogastric tube placement should undergo preoperative cranial imaging studies to verify an intact skull base.
Department of Anesthesiology, Hospital of University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA. fredallenmd@gmail.com
Frederick
F
Allen
James
J
Riopelle
Ashish
A
Sinha
D000328:Adult; D005004:Ethmoid Bone / Q000002:abnormalities* / Q000000981:diagnostic imaging*; D017809:Fatal Outcome; D005260:Female; D006053:Goldenhar Syndrome / Q000000981:diagnostic imaging* / Q000601:surgery; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000379:methods*; D011859:Radiography