2026 Poster Presentations
P015: NG TUBE-RELATED ANTERIOR SKULL BASE INSULT LEADING TO OCULOMOTOR AND TROCHLEAR NERVE PALSY
Mitchell Rheeman, BS1; Srikar Ganapathiraju, BS1; Robert Heller, MD2; Jordon Grube, DO3,4; 1Albany Medical College; 2Albany Medical Center, Department of Neurosurgery; 3Albany Medical Center, Department of Otolaryngology-Head and Neck Surgery; 4Albany Medical Center, Department of Rhinology, Sinus, and Skull Base Surgery
Introduction: Nasogastric (NG) tube placement is a routine bedside procedure for gastrointestinal decompression but carries the risk of rare, serious complications. Intracranial perforation through the cribriform plate is uncommon, particularly in awake patients, and may result in cerebrospinal fluid (CSF) leak, pneumocephalus, and cranial neuropathies. We present a rare case of NG tube-related anterior skull base injury resulting in combined oculomotor (CN III) and trochlear (CN IV) nerve palsy.
Case Presentation: A 66-year-old male with diverticulitis and bowel obstruction underwent NG tube placement while awake. Immediately afterward, he developed acute neurological deficits including altered mental status, ptosis, anisocoria, and facial asymmetry. Emergent CT revealed subdural and subarachnoid hemorrhages with extensive pneumocephalus (Figure 1. & Figure 2.). Endoscopic evaluation identified a 5 x 3 mm cribriform plate defect with active CSF leak. After initial conservative management failed, the defect was repaired endoscopically using a free mucosal graft harvested from the right middle turbinate. Postoperatively, mental status normalized and ptosis resolved, though persistent diplopia remained. Over several months of neuro-ophthalmologic follow-up, findings evolved from third nerve palsy to unmasked fourth nerve palsy with hypertropia, followed by gradual, spontaneous recovery of both nerves by eight months.
Figure 1. Initial CT Head without contrast demonstrating pneumocephalus most pronounced overlying both frontal cerebral convexities with tenting of the anterior aspects of the frontal lobes.
Figure 2. Initial CT Head without contrast demonstrating pneumocephalus overlying the anterior aspects of both middle cranial fossae.
Figure 3. Postoperative CT Head without contrast demonstrating complete resolution of pneumocephalus.
Discussion: Although rare, NG tube-related skull base trauma may occur even in alert patients, highlighting the vulnerability of the cribriform plate. Complications include CSF leak, pneumocephalus, intracranial hemorrhage, and cranial neuropathies. This case illustrates how compressive and pressure-related injury at the tentorial edge can damage both CN III and CN IV. Importantly, traumatic ocular motor nerve palsies often show favorable spontaneous recovery, underscoring the value of conservative management with close follow-up before surgical correction of diplopia is considered.
Conclusion: NG tube-associated anterior skull base injury can result in life-threatening and vision-threatening complications. Prompt recognition of neurological changes, early imaging, and interdisciplinary surgical repair are critical to preventing morbidity. Awareness of the potential for spontaneous recovery in traumatic oculomotor and trochlear nerve palsies is essential in guiding management and avoiding unnecessary intervention.