Malposition of a nasogastric tube into the middle ear of a premature one week old infant

A significant number of pediatric patients require a nasogastric tube (NGT) during their hospital stay for indications including nutrition support, medication delivery and decompression of the gastrointestinal tract. As such NGT placement is commonly performed; however, misplacement can occur into other anatomic sites within proximity. Primary Diagnosis We report a first in the literature case of NGT misplacement into the middle ear via the eustachian tube in a one-week-old premature infant that required an NGT for feeding support. Clinical Findings There was no reported resistance or concerns during NGT insertion; however, blood was noted in the syringe during aspiration performed to confirm tube position. A plain film radiograph and thereafter high-resolution computed tomography (HRCT) imagining confirmed the malposition of the tube within the middle ear. Interventions and Outcomes After transfer to a tertiary center, the NGT was removed without event in the neonatal intensive care unit (NICU) under direct vision with a flexible nasal endoscopy and successful replacement occurred thereafter. No injury to the middle ear structures or hearing occurred. Practice Recommendations While not a common site of misplacement, nasogastric tubes can be misdirected via the eustachian tube into the middle ear. Imaging modalities such as plain film radiographs and computed tomography can be helpful when misplacement is suspected based on bedside assessment. Protocols for routine replacement of functional nasogastric tubes after specific time periods in an effort to prevent nasal alar or nasal cavity complications from pressure should consider the risk of misplacement and consequences thereof.