Inadvertent brain penetration during neonatal nasotracheal intubation

During routine nasal intubation of a premature infant, the endotracheal tube penetrated the brain. Bloodstained cerebrospinal fluid and neural tissue was apparent. Initial cranial sonography was normal, but the infant later developed extensive intracranial haemorrhage. Rotation of an endotracheal tube to facilitate insertion angles the bevel at the tip upwards, increasing risk of brain penetration. Great care is required during nasal intubation; use of a small feeding tube over which to slide an endotracheal tube may be helpful.