[Accidental introduction of a naso-gastric tube into the cranial cavity in a patient with non-severe cranial and facial trauma].

The authors report the accidental insertion of a nose-gastric tube inside the brain-pan of a patient affected by a cranic-facial trauma. The wrong tubes positioning was performed at the Emergency Department of the authors' hospital; it was discovered a few minutes later when a cranic CT scan had been performed. In the meantime an important neurologic syndrome developed. The poor objective evidence of the injury, which, even though causing not very evident physical damage to the patient's face, produced a communication between the patient's nose-pharynx and brain-pan, made the case worth reporting. The aim of this report is to remember and to stress how in every case of craniofacial injury, although if of poor evidence, the insertion of a naso-gastric tube is exposed to its dislocation to the brain-pan. The tube positioning must then be performed only after a cranic CT scan showed no disruption of the anatomic structures dividing the nose-pharynx by the brain-pan. The simple skull X-ray is not sufficient.