title: 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.
authors.affiliation: SUNY Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY 11203, United States.
authors.forename: Keyur Kamlesh
authors.initials: KK
authors.lastname: Mehta
authors.affiliation: SUNY Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY 11203, United States.
authors.forename: Sabina Qureshi
authors.initials: SQ
authors.lastname: Ahmad
authors.affiliation: SUNY Downstate, Pediatric Intensivist Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY 11203, United States.
authors.forename: Vikas
authors.initials: V
authors.lastname: Shah
authors.affiliation: SUNY Downstate Medical Center, 450 Clarkson Avenue, Box 49, Brooklyn, NY 11203, United States.
authors.forename: Haesoon
authors.initials: H
authors.lastname: Lee
keywords: ARDS, acute respiratory distress syndrome; CPAP, Continuous positive airway pressure; CXR, chest radiograph; FiO2, fraction of inspired oxygen; LV, left ventricle; MRI, magnetic resonance imaging; NPPE, negative pressure pulmonary edema; Nasopharyngeal tumor; PEEP, positive end expiratory pressure; POPE (postobstructive pulmonary edema); POPE, postobstructive pulmonary edema; Pulmonary edema; RV, right ventricle; Rhabdomyosarcoma