Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc
Journal website https://jmc.elmerpub.com

Case Report

Volume 17, Number 3, March 2026, pages 128-132

Misplaced and Knotted Nasogastric Tubes in Infants and Children: Report of Two Cases

Figures

Figure 1.
Figure 1. Initial intraoperative chest radiograph revealing looping of the nasogastric (NG) tube within the esophagus and its tip in the fundus of the stomach.
Figure 2.
Figure 2. Nasogastric (NG) tube following removal showing the NG tube knotted around the endotracheal tube and the temperature probe.
Figure 3.
Figure 3. Postoperative chest radiograph obtained after attempted withdrawal of the nasogastric (NG) tube showing the NG with a knot in the proximal esophagus.
Figure 4.
Figure 4. Knotted nasogastric tube after removal by the pediatric otorhinolaryngologist.

Tables

Table 1. Risk Factors for NG Tube Knot Formation
 
ETT: endotracheal tube; NG: nasogastric.
Use of narrow bore tubes
Excessive tube length in the stomach
Gastric anatomy including small stomach volumes
Altered gastric anatomy following surgery
Vigorous peristalsis activity
Prolonged duration of tube placement
Excessive tube manipulation or movement
Rapid insertion or withdrawal of the ETT

 

Table 2. Pathway for NG Removal When Resistance Is Encountered
 
AP: anteroposterior; NG: nasogastric.
1. High index of suspicion when excessive resistance is noted on attempted NG tube removal.
2. Attempts at withdrawal should stop—never pull against resistance due to risk of esophageal or airway injury.
3. Imaging studies (lateral/AP neck or skull radiograph) may identify the knot and its position.
4. Attempt to visualize the knot in the oropharynx. If it can be seen, it may be possible to hold the knot with a forceps and cut above it.
5. The knot is then removed through the mouth with the distal end of the NG while the remainder of the NG tube (proximal end) is removed through the nare.
6. If the knot is more distal, removal under direct vision with sedation/anesthesia may be required. This may require consultation with otolaryngology or gastroenterology.