Difficult Nasogastric Tube Placement Due to an Unusual Cause and a Clinical Management Algorithm: A Case Report

Back ground: Nasogastric tube placement although usually effortless in experienced hands can sometimes pose hurdles in anaesthetised intubated patients. The association of NGT placement with several adverse events (aspiration pneumonitis, nasal mucosal/turbinate trauma, esophageal perforation, tracheobronchial placement, pneumothorax, hydrothorax, empyema, intracranial placement and vascular penetration) failing proper insertion is well documented. Literature review reveals fewer than 100 cases of Bochdalek hernia reported in adults so far and none of them describes how to manage a difficult nasogastric tube placement in these patients which makes our case report unique. Case presentation: In an ovarian cancer patient posted for cytoreductive surgery we encountered unprecedented difficulty in nasogastric tube placement despite using manoeuvres like nasal preparation (xylometazoline drops, lignocaine jelly), frozen nasogastric tube, nasal tip uplifting, gentle rotatory motion, ante-Sellicks manoeuvre, guidance between index and middle finger of the anaesthesiologist, videolaryngoscopic guidance, forceps (Magill’s; Boedecker’s), fiberoptic bronchoscopic guidance, guidewires as stylets, and oropharyngeal airway as a conduit. An extremely unusual cause of nasogastric tube misplacement surfaced on endoscopic examination by the interventional gastroenterologist. Conclusion: On analysis of the unusual case, we identified three successive levels at which hurdles, including that due to Bochdalek’s hernia, could be encountered during NGT placement and prepared an algorithm to counter them.