[Perforation of the skull base during nasogastric intubation]

The skull base was perforated and extensive wounds occurred in the brain during the passage of a nasogastric tube on a 48 year old woman, under general anaesthetic. The patient was treated by artificial respiration but died on the 14th day. The site of entry was the sphenoid sinus. False passage of the tube was favoured by a marked septal deviation, underdevelopment of the turbinates, and a high-grade pneumatisation of the paranasal sinus. 10 more cases of intracranial passage of a nasogastric tube were found in the literature.