Relief of tension pneumocephalus with endotracheal intubation

Pneumocephalus is commonly seen after neurosurgical procedures and is usually of little consequence. When an anatomical 1-way valve develops, there can be significant air entrapment, known as tension pneumocephalus. In cases of craniofacial resection, an iatrogenic ball-valve mechanism involving the nasopharynx can be created.

In this case of craniofacial resection, we find that a tension pneumocephalus developed after surgery, resulting in a change in the patient's mental status. A latissimus dorsi muscle flap, which had been created during surgery, was found to pulsate with the patient's respirations. This flap, along with the patient's nasopharynx, created a ball valve mechanism which led to entrapment and accumulation of intracranial air. This case demonstrates the use of endotracheal intubation as a means of bypassing a 1-way valve of this nature.

Endotracheal intubation in conjunction with twist drill hole aspiration effectively resolves the pneumocephalus by both providing an outlet for trapped air and by removing the ball-valve mechanism from the circuit. Endotracheal intubation should be considered along with twist drill hole aspiration in the emergent management of tension pneumocephalus secondary to a nasopharyngeal ball-valve mechanism.