Abstract
Placement of Ryle’s tube is a rather blind outpatient procedure which has documented minor and major complications during insertion like nasal irritation, epistasis, pharyngeal trauma, tracheal trauma, intravascular penetration, intracranial penetration etc. However, removal of Ryle’s tube is a rather straightforward procedure with rarely any complication. In this case report, we encountered an unusual situation of Ryle’s tube being kinked and stuck at Left Fossa of Rosenmuller, near the skull base with subsequent erosion, emphasising the fact that forceful removal should not be attempted. Thorough examination and meticulous removal are necessitated in a stuck/kinked Ryle’s tube to prevent dreaded complications.
Keywords: Ryle’s tube, Fossa of Rosenmuller, Skull base
Introduction
The insertion of Ryle’s tube is a simple routine procedure and so is its removal, done almost always in the out-patient setting. Often complications arise during insertion like pneumothorax [1], Pseudo-diverticulum [2], accidental insertion into airway leading to ventilator malfunction in debilitated patient [3]. Complications arising during removal of Ryle’s tube is an unusual phenomenon with a few cases of “True knot” being reported in literature [4]. Here, we present a rare case of Ryle’s tube being kinked and embedded at an unusual site which warranted removal under endoscopic guidance as forceful removal would have caused serious complication like skull base fracture and CSF leak.
Case Report
A young 26-year-old Female patient came to ENT OPD with a complain of inability to get Ryle’s tube removed which was previously attempted at multiple hospitals. Two months ago, while the patient was 36 weeks pregnant, eclampsia was diagnosed and underwent emergency lower segment caesarean section (LSCS) and gave birth to a healthy newborn. On post-partum day 2, she had an episode of right-side hemiparesis and was diagnosed as Left capsuloganglionic haemorrhage. The patient underwent emergency Left Fronto-temporo-parietal decompressive craniectomy with evacuation of hematoma with lax duroplasty along with Ryle’s tube insertion and tracheostomy. She had an uneventful post-operative stay and was discharged on 7th post-operative day.
Patient started taking oral feed after 45 days and was advised Ryle’s tube removal for which she went to a local hospital where it was unsuccessfully attempted and was referred to a higher center where it failed again. Finally, after 3 attempts she came to us.
On examination, her neurological status was satisfactory, she was taking oral feed and was following commands. The patient was tracheostomised and Ryles tube was partially out and stuck. On touching the Ryle’s tube, patient had excruciating pain. Xray was ordered which showed RT at the level of C4-C5 with a kink at the level of nasopharynx, adjacent to skull base (Fig. 1A, B).
Fig. 1.
A Xray AP view showing kinking of Ryle’s tube on left side of nasopharynx adjacent to skull base and reaching up to C4–C5. B Xray lateral view showing bent at the level of nasopharynx, near skull base
In the operating theatre, Nose was anesthetized with 4% Lignocaine and adrenaline pack. Oral cavity, oropharynx, Nasopharynx were anesthetized with 10% lignocaine spray. On endoscopic examination, Ryle’s tube was found adhered with inferior turbinate, along with kinking in the nasopharynx at Fossa of Rosenmuller, making a knot and tightly adhering to the skull base (Fig. 2A, B). It was surrounded with extensive granulations and mucosal hyperplasia (Fig. 2C). The Ryle’s tube was visible in the oropharynx.
Fig. 2.
A RT kinked and stuck at Fossa of Rosenmuller. B RT being slowly separated from the granulations around it at the fossa of Rosenmuller near skull base. C Showing extensive granulations post removal
The Ryle’s tube was gradually separated from the inferior turbinate with the help of Freer’s elevator. And the kinked part was slowly separated with suction elevator from skull base. After it was separated, the tube was cut at the nasopharynx, subsequently it was held with a long artery forceps in the oropharynx and the oral part was removed via mouth and the nasal part via nose. The Ryle’s tube was eroded and found kinked where it was stuck (Fig. 3A–C).
Fig. 3.
A, B Showing the eroded, kinked end of the tube. C The entire Ryle’s tube and the junction where it was cut to remove the nasal and enteral end separately
Discussion
Insertion of Ryle’s tube is indicated for numerous reasons like enteral feeding, management of critically ill patients, administration of medication or stomach decompression. The process of Ryle’s tube insertion is mostly blind. Both Minor and Major Complications arising from insertion or removal of Ryle’s tube are well documented, minor including nasal irritation, epistasis, sinusitis, and major including tracheobronchopleural complications, intravascular penetration, enteral complications, and cranial entry with mortality rate of 0.3% [5]. Numerous reasons have been postulated for complications arising during removal like faculty insertion technique, long standing tube, anatomical aberrations, peristalsis of stomach and high threshold pressure during removal [6]. There are various tests available to confirm correct insertion including X-ray and air insufflations with epigastric auscultation, pH of aspirate and bilirubin, capnography, and endoscopy [6]. but removal is essentially blind.
Caution is warranted when there is resistance during removal of Ryle’s tube or the patient is complaining of severe pain as the tube could be potentially obstructed/kinked/knotted. In our case, high resistance was felt while attempting to remove the tube along with patient complaining of severe pain only to be found adhered in Fossa of Rosenmuller with extensive granulations which required intervention.
Conclusion
Forceful removal of Ryle’s tube should not be attempted in order to prevent severe complications. Patience should be exercised during thorough examination in order to conclude the reason for perceptible resistance and act accordingly. Inadvertently neglected Ryle’s tube of long duration leads to extensive granulations and erosion of surrounding structure therefore care should be taken to meticulously remove the tube with caution. Lastly, Ryle’s tube of substandard quality should be avoided as they are more prone to complications if such a situation surfaces.
Funding
There is no funding information in this study.
Declarations
Conflict of interest
None.
Ethical Approval
This article is in compliance with the ethical standards.
Informed Consent
Informed consent was obtained from the individual participant included in this article.
Footnotes
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