Sir,
Naso-gastric tube (NGT) is usually indicated for enteral feeding or aspiration of
intestinal secretions or stomach wash in cases of suspected poisoning. But before
using this tube for any procedure, it is imperative to check and confirm the correct
position of the distal end of the tube. Because, occasionally the tube may inadvertently
enter the airway instead of the gastrointestinal tract.[1] One can easily imagine
the unfavorable outcome (from aspiration pneumonitis, pneumothorax, collapse of alveoli
to even death), once the tube remained undiscovered in trachea and enteral feeding
or stomach wash is started.[2
3] We report two patients scheduled for emergency exploratory laprotomy having acute
onset hoarseness of voice.
A 28-year-old male with perforation peritonitis and a 40-year-old female with intestinal
obstruction were scheduled for emergency exploratory laprotomy, with NGT (16 no size)
in situ. While doing preoperative assessment, hoarseness of voice was noticed in both
the cases. It was found to be acute in onset. As we could not get any other reason
other than possibility of NGT in trachea, NGT was removed without confirmation of
position in first case. As soon as the tube was taken out, patient regained normal
voice. With previous experience, it was planned to confirm position of NGT with the
help of direct laryngoscopy in second case. After explaining the procedure to the
patient, direct laryngoscopy was done and it was found that the tube was entering
into the larynx instead of oesophagus. The tube was taken out following confirmation
of wrong positioning. NGT was repositioned in oesophagus under direct laryngoscopy
and guiding with the help of Magill’s forcep after intubation, in both the cases.
Hoarseness is usually caused by a problem in the vocal cords. During phonation, the
vocal cords meet in midline and as air leave the lungs; they vibrate producing sound
[Figure 1]. Anything (FB, tumour, polyp, inflammatory reaction, vocal cord palsy),
which prevents proper approximation of cords, leads to difficulty in producing sound
when trying to speak or change in pitch or quality of voice. Voice may sound weak,
scratchy or husky. Possible common causes of sudden hoarseness of voice can be: Tonsillitis,
Adenoiditis, Heavy smoking, Alcoholism, Excessive crying, Singers, Irritant gas inhalation,
Viral illness, Ingestion of caustic liquid, Foreign body, Allergies.
Figure 1
Axial view from above the vocal folds. (a) complete vocal cord closure upto cartilagenous
portion. (b and c) During phonation- abduction and adduction of vocal cords. While
the membranous portion of vocal cords vibrate, cartilagenous portion remains open
and allow constant flow of air during phonation
Although awake, healthy persons have protective airway reflexes that prevent entry
of any FB into the trachea, but general debility and weakness lead to partial suppression
of the laryngeal reflexes.[2] Galley states, “It is well known that even in the conscious
patient the larynx has a greater tolerance for foreign bodies which do not move”.[4]
Respiratory distress, coughing, straining, and retching are not normal reactions to
the passage of a Ryle’s tube. When these occur to excess in any patient, particularly
in the exhausted, toxic, or otherwise debilitated, the tube should be under suspicion
until proved, by positive gastric aspiration, to be in the stomach.[2] So one must
always be suspicious about the incorrect position of the Ryle’s tube.
There are various methods to ascertain the position of the tube in the stomach, like
aspirating 2 mls of stomach content with a syringe and pour on litmus paper (turn
blue litmus paper red), injecting 5 ml of air into the tube (whooshing sound over
the epigastrium with stethoscope), X-ray chest and upper abdomen, pH testing of feeding
tube aspirates, capnograph, calorimetric CO2 detector.[5] Although radiologic confirmation
of tube placement remains the “gold standard”, there is growing evidence that pH testing
of feeding-tube aspirates can reduce (although not totally eliminate) reliance on
X-rays used for this purpose.[5]
We, therefore, recommend that any case of Naso-gastric tube in situ having acute onset
hoarseness of voice, one must reconfirm exact position of Naso-gastric tube, with
any of the above mentioned technique before starting procedure to avoid fatal consequences.