Inadvertent intracranial insertion of a soft rubber tube in a patient with Treacher-Collins syndrome: case report and review of literature.

CASE REPORT: An inadvertent insertion of a soft rubber tube into the intracranial compartment in a patient with Treacher-Collins syndrome is reported. The neonate was delivered vaginally at 34 weeks gestation, had bilateral choanal atresia and presented with apnea at birth. An emergency orotracheal intubation was performed, and ventilatory support was instituted. Computed tomography scan of the facial bones showed a bilateral bony choanal atresia, with a thick posterior nasal septum, and complete absence of maxillary sinuses, external auditory canal, middle ear and ossicles, and roof of ethmoid bone. There was a central cleft in the frontoethmoidal area. The inner ear and the semicircular canals were present. The patient underwent successful transpalatal repair with nasal stenting. During surgery, two unsuccessful attempts to negotiate a soft rubber tube through the occluded choana were made. Postoperative magnetic resonance imaging revealed a linear hemorrhagic tract created by the soft rubber tube coursing through the anteroinferior basal frontal lobe, thalamus, basal ganglia and terminating in the occipital lobe. The patient developed bacterial meningitis, communicating hydrocephalus followed by cerebrospinal fluid rhinorrhea. A transcranial repair of the anterior cranial fossa was performed followed by ventriculoperitoneal shunt insertion. Subsequently, he underwent shunt revision for suspected shunt malfunction and developed peritoneal abscess for which the shunt was exteriorized and later removed. An endoscopic third ventriculostomy was performed, and the patient is recovering well.

DISCUSSION: The potential implications of an inadvertent foreign body penetration into the intracranial compartment in such a rare event are discussed and the relevant literature is briefly reviewed.