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Canadian Journal of Anesthesia 50:622-623 (2003)
© Canadian Anesthesiologists' Society, 2003

Correspondence

Aspiration pneumonia associated with a giant epiglottic cyst after cardiac surgery

MinHye So, MD1, Kazuya Sobue, MD PhD1, Hajime Arima, MD1, Tetsuro Morishima, MD1, Masatoshi Fukumoto, MD1, Sayuki Tanaka, MD1, Hiroshi Ando, MD PhD1 and Hirotada Katsuya, MD PhD2

1 Obazaki, Japan
2 Nagoya, Japan

To the Editor:

Epiglottic cysts are found incidentally during induction of general anesthesia and can hamper tracheal intubation.1 Several methods have been reported to overcome these situations, however, to our knowledge, there has been no report of postoperative respiratory complications in patients with epiglottic cysts. We describe a patient with a giant asymptomatic epiglottic cyst who developed aspiration pneumonia after cardiac surgery.

A 71-yr-old man (height 154 cm, weight 42 kg) was scheduled to undergo coronary artery bypass grafting. During induction of general anesthesia, a giant epiglottic cyst was found (FigureGo). Though manual ventilation was easy, the cyst had almost obstructed the larynx and tracheal intubation was difficult. The surgery was carried out uneventfully and he was admitted to the intensive care unit for postoperative management. On postoperative day one (POD1), he was extubated and his respiratory state was stable. On POD2, he was able to drink water and the cough reflex was present. Immediately following the reintroduction of solid food, he developed aspiration pneumonia of the right lower lobe. Mechanical ventilation and administration of antibiotics proved effective and the cyst was removed surgically on POD5 under general anesthesia. The postoperative course after cystectomy was uneventful and oral intake was normal.



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  		FIGURE A giant epiglottic cyst was found incidentally at laryngoscopy. The larynx was almost obstructed by the cyst.

 
There are several factors that increase the risk for aspiration pneumonia after surgery; namely, loss of protective airway reflexes, vomiting, pregnancy, obesity, diminished level of consciousness, anatomic distortion of the airway and a history of cerebrovascular disease.2,3 Especially after cardiac surgery, age and duration of intubation are independent predictors of swallowing dysfunction.4 In our patient, age, the residual effects of anesthetics, the use of transesophageal echocardiography, duration of intubation and anatomic distortion due to the giant epiglottic cyst are all possible factors explaining aspiration. We cannot tell which factor was predominant. However, the presence of this large epiglottic cyst may have resulted in postoperative epiglottic dysfunction and aspiration of solid food.

References

1 Dada MA. Laryngeal cyst and sudden death. Med Sci Law 1995; 35: 72–4.[Medline]

2 Mecca RS. Pulmonary aspiration syndrome. In: Kirby RR, Gravenstein N, Lobato EB, Gravenstein JS (Eds.). Clinical Anesthesia Practice, 2nd ed. Philadelphia: W.B. Saunders Company; 2002: 101–3.

3 Harrington OB, Duckworth JK, Starnes CL, et al. Silent aspiration after coronary artery bypass grafting. Ann Thorac Surg 1998; 65: 1599–603.[Abstract/Free Full Text]

4 Hogue CW Jr, Lappas GD, Creswell LL, et al. Swallowing dysfunction after cardiac operations. Associated adverse outcomes and risk factors including intraoperative transesophageal echocardiography. J Thorac Cardiovasc Surg 1995; 110: 517–22.[Abstract/Free Full Text]





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