Esophageal polyp as a posterior mediastinal mass: Intraoperative dynamic airway obstruction requiring emergency tracheostomy
A 24-year-old 52 kg male was diagnosed with esophageal polyp and posted for elective polypectomy via transcervial approach. On preoperative evaluation, there was history of dysphagia, pressure sensation in throat and exertional breathlessness grade II for last 3 months. The symptoms were unrelated to change in position. No history of hoarseness of voice, congestion or puffiness of face, syncope, or palpitation was present. On examination, his pulse was 86/minute, blood pressure 110/70 mmHg and respiratory rate 20/minute. Airway examination was unremarkable.\nHematological and biochemical investigations were unremarkable. Chest X-Ray lateral view revealed a mass in the posterior mediastinum. Computed tomography (CT) scan of chest showed an intraluminal pedunculated polypoidal lesion of 10 × 4 cm size extending from upper end of esophagus to the junction of middle and lower third of esophagus with compression of lower end of trachea and both the bronchi. Tracheobroncheal compression ratio was less than 50%. Preoperative flow volume study and esophagography were not done.\nSedative premedication was avoided. In the operating room, intravenous access was obtained; a flexible fiber-optic bronchoscope, a rigid bronchoscope, and tracheostomy set were kept ready. After adequate preoxygenation, anesthesia was induced with gradually increasing concentration of sevoflurane. After confirming bag and mask ventilation, inj. Succinylcholine 100 mg was administered and fiberoptic bronchoscope guided tracheal intubation was performed with 8.0-mm polyvinylchloride (PVC) endotracheal tube (ETT). The tip of the ETT was kept in the compressed lower end of the trachea. However, both the main bronchi were found to be compressed as well. But ventilation was adequate and airway pressure was normal. Two wide bore intravenous access and left radial artery canula were taken. Anesthesia was maintained with oxygen, air, isoflurane, morphine, and intermittent dose of vecuronium.\nAfter an oblique cervical incision, esophagotomy was performed and the polyp was attempted to be pulled up. Initial 3-4 cm of the mass was exited smoothly but after that increasing resistance was encountered and the polyp could not be pulled up any further. Airway pressure increased from 18 to 42 cm H2O. Manual ventilation was started. Any ETT kinking/obstruction, distal migration into the bronchus and bronchospasm were ruled out. Manual ventilation became increasingly difficult, end-tidal CO2 reached 65-70 mm Hg and airway pressure 40-45 cm H2O. Increased external compression of the tracheobroncheal tree by the pulled up polyp was likely diagnosis. Attempts to push the mass back into the mediastinum with an expectation to relieve the obstruction also failed. Oxygen saturation decreased to 86%. Emergency tracheostomy was immediately performed which revealed a compressed ETT inside trachea; a gum-elastic bougie was introduced into the tracheostomy stoma and a reinforced flexometallic 8.0-mm ETT was advanced over the bougie forcibly to bypass the obstruction. Immediately airway pressure declined and SpO2 improved. Rest of intraoperative course remained uneventful. The mass was successfully retrieved transcervically and resected []. His tracheostomy tube was decannulatd after 2 weeks after ruling out any possible tracheomalacia.