Revista nº 801

Yolanda Baca Morilla

Aspiration pneumonia in patients underwent head and neck surgery

Patient 2: A 36-year-old man underwent surgical drainage

of a neck abscess (dental origin). A cervical approach was used

to reach the submandibular space. A NG tube was placed imme-

diately following surgery. Three days after, patient showed fever

and leukocytosis. In light of the above, we decided to perform a

chest x-ray. This test evidenced a bilateral aspiration pneumonia.

Promptly, the enteral tube nutrition was stopped and an empi-

rical antibiotic treatment was administered. Importantly, this

patient evolved favorably too and was discharged from intensive

care unit 17 days later.

Patient 3: A 61-year-old man underwent major head and

neck surgery. In fact, patient was diagnosed with squamous cell

carcinoma. A NG tube was placed just after the surgery. Four

days after, patient showed fever, refractory hypoxemia and leu-

kocytosis. In view of that, a chest x-ray was carried out. This test

evidenced a bilateral aspiration pneumonia. Once again, the

enteral tube nutrition was stopped and an empirical antibiotic

treatment was administered. The patient evolved favorably and

was discharged from hospital 61 days later.

Patient 4: A 63-year-old man underwent major head and

neck surgery. Patient was affected by squamous cell carci-

noma of the tongue and floor of the mouth. Due to the ex-

tension of tumorectomy a pectoral flap was used for recons-

tructing the oncological defect of the oral cavity. Inmediately

after surgery, a NG tube was placed in order to guarantee an

adequate nutritional status of the patient. Six days after, pa-

tient presented fever, refractory hypoxemia and leukocytosis

associated with signs and symptoms of sepsis. Considering

all of this, we performed a chest x-ray. This test evidenced

a lobular aspiration pneumonia. As before, the enteral tube

nutrition was stopped and an empirical antibiotic treatment

was administered. This patient evolved favorably too and was

discharged from hospital 43 days later.

DISCUSSION

Nasogastric (NG) tubes are essential for patients who

present swallowing problems. In fact, this tool ensures suffi-

cient nutrition to meet daily patient requirements (4). In

addition several drugs might also be administered through

this way (5). However, several complications may be asso-

ciated with the presence of NG tubes. Increase in gastric re-

sidue, constipation, diarrhea, abdominal distention and re-

gurgitation of food represent some possible gastrointestinal

complications of NG tube (6). On the other hand, death or

severe harm might be provoked by the misplaced of the na-

sogastric tube in the respiratory tract (7). In this line, serious

aspiration pneumonia or sever acute respiratory distress syn-

drome might be triggered by contact of the enteral nutrition

with the pulmonary parenchyma (8). Several test methods

were studied to verify the correct position of NG tube af-

ter it placement (9). For instance, the gastric auscultation of

bubbles after an air injection across the NG tube is a techni-

que used for verifying the correct position of the probe. The

measurement of acidity with litmus paper or with a pH paper

are also employed in order to confirm the adequate position

of the NG tube. However, this tests not ensure the neces-

sary degree of reliability in all cases. Moreover, is important

to underline that the placement of a NG tube is technically

more difficult in some patient. Specifically, patient with alte-

red state of consciousness or patients presenting anatomical

alterations of the upper aero-digestive path are more incli-

ned to suffer a dislocation of the NG tube into the respiratory

tract. In view of the above considerations, we consider that

patient underwent major head and neck surgery should be

considered high risk patients for NG tube placement. Against

this background, we strongly believe that a chest x-ray should

always be carried out after a NG tube placement in these ca-

ses. Obviously, rx control must be performed before before

starting the enteral nutrition. This report raises four central

points. First is the correlation between aspiration pneumonia

and head and neck surgery. In fact, the surgical aggression of

the upper aero-digestive path associated with the immuno-

suppressive state induced by surgery and the need of enteral

nutrition for long time periods predispose patients to deve-

lop respiratory complications of NG tube. Second, in these

patients a radiographic control for confirming the correct po-

sition of NG tube is mandatory. The anatomical alteration the

upper gastrointestinal tract could interfere with the place-

ment of the NG tube. Third, Research is urgently required on

how to avoid tube misplacement. Respiratory complication

caused by an incorrect position of NG tube may contribute to

increase patient postoperative morbidity and mortality.

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