Nasogastric tube placement perforating the nasopharynx causing mediastinal passage and feeding into the pleural space

A mid-60s female with known primary progressive multiple sclerosis was admitted to our hospital with aspiration pneumonia. Due to reduced consciousness, a nasogastric (NG) tube was inserted for feeding. A chest x-ray (CXR) report from a thoracic radiologist confirmed an atypical tip position due to a hiatus hernia but concluded it was almost certainly within the stomach. However, after deteriorating on feed commencement, a CT scan of the chest confirmed the tube had perforated the nasopharynx and run parallel to the oesophagus through the mediastinum into the right pleural space. The patient subsequently developed an empyema and pneumothorax, requiring multiple therapeutic interventions and a prolonged hospital stay. This case demonstrates how the routine insertion of an NG tube can lead to serious complications. Additionally, position check CXRs can be difficult to interpret, so the decision to use the tube must be made cautiously by the clinical team.