What Is the Most Serious Potential Complication of Nasopharyngeal Airway Insertion?

A nasopharyngeal airway (NPA) provides a less invasive alternative to endotracheal intubation. It is commonly used in emergencies to maintain a patient's airway patency, particularly in managing unconscious patients with intact gag reflexes. However, the NPA insertion operation looks easy; it may cause catastrophic risks. The most serious potential complication is intracranial placement through the cribriform plate of the ethmoid bone, which can result in direct brain injury, cerebrospinal fluid leakage, and even death. Reading now to learn how to minimize risks.

Potential Complications of NPA Insertion

Before the most severe complication, it's important to get to know the range of potential adverse events that can occur during NPA insertion.  

Common but Relatively Minor Complications

Nasal mucosal trauma and epistaxis represent the most frequent complications. The nasal cavity's rich vascular supply makes bleeding almost inevitable during insertion, though this is usually minor and self-limiting. Healthcare providers should be prepared to manage nosebleeds and monitor for aspiration risk, especially when using nasal trumpets in prehospital or emergency care settings.

Pressure necrosis of nasal tissues can develop with prolonged placement. Extended use of improperly sized NPAs may cause compression injury to the nasal alae or nasal septum, leading to tissue breakdown and ulceration. This complication emphasizes the importance of proper sizing and regular assessment.

Inadvertent placement into the wrong anatomical spaces occurs when the NPA is inserted too deeply or at incorrect angles. The device may enter the soft tissues of the nasopharynx rather than following the intended pathway, potentially causing local trauma and reducing effectiveness.

Gag reflex stimulation and aspiration can occur if the NPA is too long or stimulates the posterior pharynx. This may trigger vomiting, laryngospasm, or aspiration pneumonia, particularly in patients with diminished protective reflexes.

Read: Complications of a  nasopharyngeal airway too long (blog)

The Most Serious Complication: Intracranial Placement

Anatomical Basis and Mechanism

The cribriform plate of the ethmoid bone forms a thin, perforated barrier between the nasal cavity and the anterior cranial fossa. This sieve-like structure, naturally weakened by multiple foramina for olfactory nerve passage, represents the most vulnerable point for NPA misplacement. When basilar skull fractures or congenital anomalies compromise this structure, the risk of intracranial penetration increases dramatically.

Intracranial placement occurs when the NPA accidentally penetrates the cribriform plate and enters the cranial vault. This catastrophic event typically results from several factors: forceful insertion, incorrect insertion angle (directed cephalad rather than posteriorly), or insertion in patients with unrecognized basilar skull fractures. These risks are especially relevant for field applications involving the nasopharyngeal airway army, where rapid airway access is often critical, but anatomical assessment may be limited.

Devastating Consequences

The consequences of intracranial NPA placement are severe and potentially fatal:

Direct brain tissue injury occurs when the NPA tip penetrates the cerebral cortex, causing immediate neurological damage. This mechanical injury destroys brain tissue and can result in permanent neurological deficits or death.

Cerebrospinal fluid leak develops when the dura mater is breached, leading to CSF rhinorrhea. This creates a direct communication between the sterile intracranial space and the contaminated nasal cavity, significantly increasing infection risk.

Intracranial hemorrhage may result from vascular injury during NPA insertion. Blood accumulation within the confined cranial space can cause dangerous increases in intracranial pressure, leading to brain herniation and death.

Meningitis and brain abscesses represent serious infectious complications. The breach in normal anatomical barriers allows bacterial invasion of the central nervous system, potentially causing life-threatening infections.

Risk Factors and Prevention

High-Risk Patient Populations

Patients with basilar skull fractures represent the highest risk group. Clinical signs include Battle's sign (mastoid bruising), raccoon eyes (periorbital ecchymosis), CSF otorrhea or rhinorrhea, and hemotympanum. These findings indicate potential cribriform plate disruption and absolute contraindication to NPA use.

Pediatric patients face increased risk due to thinner, more fragile skull structures. The cribriform plate in children is particularly vulnerable to injury, making careful assessment essential before NPA insertion.

Patients with facial trauma or suspected midface fractures require careful evaluation. Severe craniofacial injuries may involve basilar skull fractures that are not immediately apparent, increasing the risk of intracranial placement.

Prevention Strategies

Healthcare providers must carefully evaluate for signs of basilar skull fracture, including neurological examination and assessment of facial trauma patterns. When in doubt, alternative airway management techniques should be employed.

Proper insertion technique significantly reduces complication risk. The NPA should be well-lubricated and inserted gently along the nasal floor, directed posteriorly toward the occiput rather than the cephalad.  Comprehensive Guide on How to Insert NPA?

Providers should never force insertion against resistance.

Appropriate sizing ensures safe placement. The NPA should be measured from the nostril to the earlobe, with the internal diameter corresponding to the patient's nostril size without causing blanching of nasal tissues.

Use of quality devices with proper design features enhances safety. Modern NPAs should feature rounded, beveled tips for atraumatic insertion, secure flanges to prevent over-insertion, and size markings for proper selection. Devices should be latex-free, sterile, and individually packaged.

Management of Suspected Intracranial Placement

When intracranial placement is suspected, immediate action is required to prevent further injury and complications.

Cessation of insertion and careful stabilization of the NPA in its current position prevents additional trauma. The device should not be advanced further or removed without neurosurgical consultation, as removal may cause additional injury or worsen hemorrhage.

Immediate imaging with CT scanning confirms the NPA position and assesses for associated injuries. Imaging helps determine the extent of intracranial penetration and guides treatment decisions.

Urgent neurosurgical consultation is mandatory. Neurosurgeons must evaluate the need for surgical removal, management of CSF leaks, and treatment of any associated brain injuries. The complexity of these cases requires specialist expertise.

Supportive care includes monitoring for neurological changes, managing increased intracranial pressure, and preventing secondary complications. Patients require intensive monitoring in appropriate care settings.

Conclusion

While the nasopharyngeal airway is an essential device in emergency airway management, the most serious potential complication, intracranial placement, can result in permanent neurological injury or death. Though rare, it must always be considered. Healthcare providers must maintain a heightened awareness of this complication, particularly when managing patients with facial trauma or suspected basilar skull fractures.

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