Postobstructive pulmonary edema after biopsy of a nasopharyngeal mass

Abstract

We describe a case of 17 year-old male with a nasopharyngeal rhabdomyosarcoma who developed postobstructive pulmonary edema (POPE) after removing the endotracheal tube following biopsy. He developed muffled voice, rhinorrhea, dysphagia, odynophagia, and difficulty breathing through nose and weight loss of 20 pounds in the preceding 2 months. A nasopharyngoscopy revealed a fleshy nasopharyngeal mass compressing the soft and hard palate. Head and neck MRI revealed a large mass in the nasopharynx extending into the bilateral choana and oropharynx. Biopsy of the mass was taken under general anesthesia with endotracheal intubation. Immediately after extubation he developed oxygen desaturation, which did not improve with bag mask ventilation with 100% of oxygen, but improved after a dose of succinylcholine. He was re-intubated and pink, frothy fluid was suctioned from the endotracheal tube. Chest radiograph (CXR) was suggestive of an acute pulmonary edema. He improved with mechanical ventilation and intravenous furosemide. His pulmonary edema resolved over the next 24 h. POPE is a rare but serious complication associated with upper airway obstruction. The pathophysiology of POPE involves hemodynamic changes occurring in the lung and the heart during forceful inspiration against a closed airway due to an acute or chronic airway obstruction. This case illustrates the importance of considering the development of POPE with general anesthesia, laryngospasm and removal of endotracheal tube to make prompt diagnosis and to initiate appropriate management.

Negative pressure pulmonary edema: a case report

“…In clinical practice, when unexplained pulmonary edema takes place, NPPE should be considered in different diagnosis, although it is uncommon [3]. In the meanwhile, this case included other similar aspects of NPPE, for example, rapid onset of pulmonary edema after efforts at inspiration against obstructive airway [3] and rapid resolves within 12 to 24 hours [7]. In addition, normal ejection fraction also led us from cardiogenic pulmonary edema to non-cardiogenic pulmonary edema.…”

Negative pressure pulmonary edema in a patient undergoing open rhinoplasty

“…Several NPPE cases have reported following nasal surgery. [ 9 – 11 ] In 2006, Westreich et al [ 3 ] reviewed 146 NPPE patients of which 8% had undergone intranasal surgery. The nasal packing requirements of these procedures reduce the efficiency of mask ventilation after extubation.…”

Negative pressure pulmonary edema: a case report

“…In clinical practice, when unexplained pulmonary edema takes place, NPPE should be considered in different diagnosis, although it is uncommon [3]. In the meanwhile, this case included other similar aspects of NPPE, for example, rapid onset of pulmonary edema after efforts at inspiration against obstructive airway [3] and rapid resolves within 12 to 24 h [7]. In addition, normal ejection fraction also led us from cardiogenic pulmonary edema to non-cardiogenic pulmonary edema.…”