A rare presentation of large polypoidal growth from pyriform fossa causing airway challenge

Dear Editor,

Polypoidal growths of the hypopharynx are rare presentations that are either hamartomatous, inflammatory post-traumatic, or secondary to prolong gastroesophageal reflex or ectopic gastric mucosa.[1,2,3] Apart from being a surgical challenge, they are associated with perioperative difficulty, including proper intubation and even securing the airway post-intubation.[4]

A 55-year-old male patient was planned for a biopsy of an unusual mass from the pyriform fossa. The patient was American Society of Anesthesiologist (ASA) grade 2, body mass index (BMI) 26 kg/m², had mild dyspnea, slight pain in the neck during deglutination, and discomfort with solid foods. Airway examination did not reveal any abnormality. His blood investigations were within normal limits except for hemoglobin, which was 7.5 gm%. The radiological workup included a barium swallow chest X-ray (frontal, lateral view), which showed a large polypoidal lesion from the left pyriform sinus with inferior eccentric submucosal extension up to the lower esophagus [Figure 1a]. Contrast-enhanced computed tomography (CECT) thorax and abdomen confirmed a large oblong pedunculate hypo-dense polypoidal lesion with internal vascular stalk arising from oropharynx extending from palatine tonsil level into esophagus till the level of the gastroesophageal junction with epicenter at left pyriform sinus. There was tracheal narrowing at the T1-2 level [Figure 1b-c]. An endoscopy evaluation also suggested extrinsic esophageal compression, with edematous mucosa seen over the laryngopharynx.

Figure 1.

Chest X-ray displaying the mass after barium swlaoow in a; b-c showing the sagittal and axial CT scans with narrowing of the trachea (arrow marked)

The patient was planned for awake fiberoptic intubation (AFI). After nebulization with 4% lignocaine, injection glycopyrrolate 0.2 mg intravenous (IV) was given. Injection dexmedetomidine infusion was then started at 0.5 μg/kg IV over 10 minutes. Lignocaine spray 10% puffs were given to the patient, and supplemental 2 ml of intratracheal lidocaine 2% was also injected. The patient then received oxymetazoline nasal drop into two nostrils as the AFI procedure using the “spray as you go technique” was followed. A pedunculated mass in the pyriform fossa was seen on fiberoptic examination, which was also hanging over vocal cords, and identifying vocal cord was difficult [Figure 2a and b]. We could reach the trachea with great difficulty as the tracheal lumen was constricted below the vocal cords [Figure 2c]. We intubated with a cuffed endotracheal tube of size 6.5 mm, which was already selected for intubation because of the airway's anticipated narrowing based on CECT findings, bilateral air entry was confirmed, and general anesthesia (GA) was induced. The surgeons took a biopsy of the mass. Post-procedure, spontaneous ventilation was allowed with continuous sedation. A fiberoptic bronchoscope ruled out tracheomalacia before extubation. The reversal was done with inj. neostigmine 5 mg IV and glycopyrrolate 0.4 mg IV, and the trachea was extubated.

Figure 2.

Fiberoptic laryngoscopopic pictures showing mass from pyriformis fossa (a), going down in the laryngopharynx (b), constrictionion of trachea can be appreciated (c)

Polypoidal growths of the esophagus and hypopharynx are exceedingly rare.[1,2] Alobid et al.[5] reported sudden death following asphyxiation, as the polyp prolapsed into the oropharynx, partially obstructing the airway. We found the mass traversing from the pyriform fossa submucosally into the esophagus. It had compressed the tracheal lumen at the T1-2 level. Preoperative thorough radiological evaluation of the airway is mandatory for proper anesthesia planning.[6] AFI is the approach for safe intubation, allowing GA for the surgery.[3,4] Anesthetic concerns were altered anatomy of the vocal cords, tracheal constriction, and tracheomalacia risk. Hence, a back-up plan of tracheostomy is pertinent in case of any inadvertent loss of airway. We found the mass hanging over the laryngopharynx and partially covering the glottis during inspiration. The patient had mild dyspnea, but there was a possibility of sudden airway obstruction. Timely identification of the abnormality and securing the airway safely is the key to managing the case. Tracheomalacia can be an acquired condition following prolonged extrinsic compression.[7] The condition is grave and must be ruled out by bronchoscopy and may require a prophylactic tracheostomy following excision of the mass.[7] As there was no direct mass sitting over the trachea, a compression was present from the posterior wall from the esophagus, so we were fortunate to find the absence of tracheomalacia. However, it should be excluded whenever extubation is planned in such surgeries to prevent inadvertent mishap.

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