Ball-valve Obstruction Research Articles

Aryepiglottic Cyst Developed Hours After Tracheal Intubation Causing Acute Upper Airway Ball-Valve Obstruction: A Case Report.

This is the first case report describing an aryepiglottic cyst resulting in critical airway compromise after an uneventful tracheal intubation. We present the case of a 55-year-old woman who developed acute dyspnea and stridor several hours after the surgery. She was found to have significant upper airway obstruction owing to a large left aryepiglottic cyst with a ball-valve effect.

Fatal airway obstruction due to a ball-valve clot with identical signs of tension pneumothorax

Endo-tracheal tube obstruction due to an extensive blood clot is a recognized but very rare complication. A ball-valve obstruction in the airway could function as a check valve for the lung and thorax, resulting in tension pneumothorax-like abnormalities. A 47-year-old female patient had undergone implantation of a left ventricular assist device 3 weeks prior. On post-operative day 17, planned thoracentesis was performed for drainage of a pleural effusion. Despite the drainage, the patient’s oxygenation did not improve, and emergency tracheal intubation was conducted. Subsequent computed tomography revealed bilateral pneumothorax. Two days later, the patient’s trachea was extubated without complication, and a mini-tracheostomy tube was placed. Three hours later, reintubation was conducted due to progressive tachypnea. Although successful intubation was confirmed, ventilation became increasingly difficult and finally impossible. Marked increase in pulmonary artery and central venous pressures suggested progression of the previous tension pneumothorax. After emergency extracorporeal membrane oxygenation was initiated, fiberoptic bronchoscopy revealed the presence of a massive clot and ball-valve obstruction of the endotracheal tube. Two weeks later, the patient died due to severe hypoxic brain damage. Diagnosis of ball valve clot is not simple, but intensivists should consider this rare complication.

Gastric Leiomyoma Causing GOO in a Roux-en-Y Gastric Bypass Patient

Gastric leiomyomas (GLM) are rare tumors of the stomach, and they account for about 2.5% of all gastric tumors. They are classified as superficial or deep depending on origination. Symptoms are rare unless there is bleeding, malignant transformation, or significant growth to cause an outlet obstruction. Here we will discuss a case about a 57-year-old, African American female with history of Roux-en-Y gastric bypass who presented with gastric outlet syndrome that was later found to be due to GLM. A 57-year-old female with history of uterine leiomyoma and history of Roux-en-Y gastric bypass presented with abdominal pain associated with nausea and vomiting in the emergency department. CT scan of her abdomen/pelvis showed the gastric remnant to be distended, measuring 6.0 x 5.4 cm with an air-fluid level. There was also thickening of the pylorus and proximal duodenum suggesting a gastric outlet obstruction. She was taken to the operating room for laparoscopic evaluation with intraoperative endogastroduodenoscope (EGD). Gastrotomy was made in the gastric remnant which allowed the EGD to pass into it. The EGD was able to transverse the pyloric channel and get into the duodenum. On withdrawing of the EGD, the GI team found a bilobulated 2-3 cm polypoid mass on the gastric antrum side of the pylorus forming a ball-valve obstruction of the pyloric channel. The mass was removed via anterior gastrostomy laparoscopically by sharp scissor. The histomorphology and immunoprofile support the diagnosis of leiomyoma of the stomach. Her recovery was unremarkable and she was discharged four days after the surgery. The above patient's altered anatomy from the Roux-en-Y made the diagnosis challenging and noteworthy. Her gastric bypass was done in 2000 without screening EGD. Current guidelines suggest that the decision to perform preoperative EGD should be individualized in patients scheduled to undergo bariatric surgery. Most bariatric surgeons request screening EGD prior to bypass surgery to look for any lesions that might need surveillance such as ulcers, polyps, or tumors. If these lesions are found before the bariatric surgery, then they can be treated. Otherwise the patient can be offered remnant gastrectomy if the lesion requires surveillance. Current guidelines should consider adding that a preoperative EGD be completed on all gastric bypass patients to assess the risk of developing disease in the gastric remnant.

Unusual case of chronic heart failure acutisation

E-mail: tatjana.zekic@ri.t-com.hr Introduction: Chronic heart failure (CHF) is a result of many different causes, but rarely occurs due to intraatrial masses. Most commonly seen are thrombi related to atrial fibrillation (AF), valvular vegetations and cardiac tumors (mixomas), but the dignosis of extensive mass reaching from the inferior vena cava (IVC) to the right atrium of the heart is an extreme rare finding. The literature reported tumor spread in 1-4% cases of hepatocellular carcinoma (HCC). We report a similar case causing the acutisation of CHF. Case report: A 83-year-old man reported to the emergency department (ER) for several times in four months due to progressive dyspnea and leg swelling. His medical history included alcoholic liver cirrhosis with hepatocellular carcinoma (HCC) treated by chemoembolisation four years ago, CHF, valvular heart disease, chronic renal disease 3b, AF. He was treated with warfarin therapy for a few months due to the patient noncompliance and also with beta-blocker, digitalis and loop diuretic, whose dose was repeatedly increased after each subsequent visit to the ER. MSCT pulmonary angiography excluded pulmonary embolism. Abdominal ultrasound showed compensated liver chirrosis with solitary HCC. At the time of our examination he had signs of heart failure along with liver decompansation. The abdominal ultrasound noted a mass extending from inferior hepatic vein through IVC all the way to the right atrium which was sized 2.7 cm. Given the extent of malignant disease and the complications, the patient was treated with low molecular weight heparin with gradual impairment of heart and kidney parameters. He died shortly after the admission of bleeding from the upper gastrointestinal tract. Discussion: The literature suggests that right atrial thrombus may not cause any symptoms, but can sometimes lead to shock from ball valve obstruction of the tricuspid valve, right heart failure, pulmonary emboli and sudden death. This patient had many comorbidities that contribute to the thrombus development and also to heart failure, but HCC is known for its ability to progress through veins. Very high mortality rates are observed for advanced HCC with IVC and intraatrial tumor thrombus extension. Mean survival time is around three months. Pharmacotherapeutic and surgical treatments is equally poor. Conclusion: The patients with progressive heart failure and liver cirrhosis with HCC should be suspected of having masses of IVC or right atrium that is easily detected by echocardiography or abdominal ultrasound. In our case it was probably spreading of tumor itself.

English

Small bowel obstruction resulting from stone impaction is very rare, with most cases caused by a gallstone ileus or by an enterolith formed in a small bowel diverticulum. We report a rare case of distal small bowel obstruction caused by a calcified enterolith, but our case is unique due to its large size causing ball valve obstruction of ileum, at the site of stricture

Understanding the Mechanics of Laryngospasm Is Crucial for Proper Treatment

To the Editor: In their case scenario, “Perianesthetic management of laryngospasm in children,” Orlianguet et al. 1presented a 10-month-old boy who developed an inspiratory stridor after sevoflurane induction, which was initially managed by a jaw thrust and positive pressure ventilation. When the stridor recurred, manual ventilation became difficult with increased resistance to insufflation. Despite a jaw thrust, positive pressure ventilation with FIO2= 1, and propofol, the obstruction was not relieved and severe hypoxemia (oxygen saturation measured by pulse oximetry, or SpO2, = 52%) ensued, requiring the administration of succinylcholine and tracheal intubation.A basic understanding of the mechanics of laryngospasm is crucial for proper treatment.2In his classic article, Fink described three types of laryngospasm: expiratory stridor, inspiratory stridor, and ball-valve obstruction.3The stridors are controlled by the intrinsic laryngeal muscles, whereas the ball-valve closure is controlled by both the intrinsic and extrinsic laryngeal muscles. The expiratory stridor occurs as a result of active adduction of the vocal cords. The inspiratory stridor is produced passively as a result of the loss of tone of the abductor muscles. Because the velocity is greater where the passage is most narrow, airway pressure at the subglottic area becomes less than atmospheric during inspiratory efforts, and the passage of gases through the glottis generates a force that approximates the vocal cords together resulting in inspiratory stridor. Positive airway pressure can stent the airway and correct both expiratory and inspiratory stridors.3In ball-valve obstruction, laryngeal closure occurs at three levels: the true vocal cords, the false cords, and the redundant supraglottic tissue.3,4The approximation of the vocal cords (and false cords) is swiftly followed by contraction of the extrinsic laryngeal muscles, shortening of the thyrohyoid distance resulting in complete closure, and cessation of airflow.3,4In this situation, applying positive pressure can worsen the obstruction,3as evidenced in the current case. By distending both pyriform fossae, the aryepiglottic folds are pressed more firmly against each other, which reinforces the closure.3In contrast, the jaw thrust (also referred to as maximum mandibular advancement)5can be effective in correcting ball-valve closure. The forward mandibular movement is transmitted through the geniohyoid muscles to the hyoid bone and the hyoepiglottic ligament. Consequently, the epiglottis and the redundant supraglottic tissue are pulled away from the false cords, and the laryngeal passage is reopened.3However, it is frequently necessary, as in the case presented by Orlianguet et al. , to administer succinylcholine to relieve this type of severe obstruction.It is interesting that the expiratory stridor, which was common in the days of ether anesthesia and was regarded as “a vocal protest by the patient against inadequate anesthesia,” has virtually disappeared in modern anesthesia practice. In our recent quality-improvement study of laryngospasm, expiratory stridor did not occur in any patient. This is probably related to the use of sevoflurane yielding faster induction because of its low blood/gas partition coefficient.We propose a simple algorithm (fig. 1) for the management of laryngospasm, which can be easily remembered and utilized by clinicians. Based on the mechanics of laryngospasm, this algorithm addresses both inspiratory stridor and ball-valve obstruction, but ignores the expiratory stridor because it is no longer observed in modern anesthesia practice. Positive pressure, which is effective in the management of inspiratory stridor, is avoided in ball-valve obstruction because it can worsen the obstruction. If a jaw thrust fails to correct ball-valve obstruction, succinylcholine is administered, followed by positive pressure ventilation and tracheal intubation.

Acute Postoperative Negative-pressure Pulmonary Edema

We read with interest the case scenario regarding acute postoperative negative-pressure pulmonary edema (NPPE).1The authors elegantly discussed the diagnosis, differential diagnosis, epidemiological features, pathogenesis, and clinical management of NPPE. We are concerned that anesthetic management may have inadvertently contributed to the cause of this complication. The patient described was given opioid doses equivalent to 27.5 mg iv morphine (0.25 mg fentanyl = 25 mg + 0.5 mg hydromorphone = 2.5 mg)2and a nondepolarizing muscle relaxant. The fact that the patient (with a normal airway) developed laryngospasm after extubation suggests that the patient was not ready for extubation. In addition, it is possible that reduced pharyngeal muscle tone due to residual neuromuscular blockade resulted in upper airway obstruction.3,4A patient with a “train-of-four” ratio of 0.9 or greater may still develop postoperative hypoxemia5and may require the administration of reversal drugs.The initial difficulty in mask ventilation after extubation implies that the inspiratory stridor had progressed to a ball–valve obstruction.6Applying positive airway pressure under these circumstances may actually worsen ball–valve closure.6Inflation of the pharynx distends the piriform fossae, pressing the aryepiglottic folds more firmly against each other and reinforcing the closure.6We suggest that the complication presented could have been prevented by delaying extubation.*Advocate Illinois Masonic Medical Center, Chicago, Illinois. mrsalem@sbcglobal.net

Unusual cause of rapidly progressive right-sided heart failure: aortic sinus of Valsalva aneurysm causing ball valve obstruction of the tricuspid valve

A rare presentation with rapidly progressive right heart failure due to tricuspid inflow obstruction (simulating right-sided valvular heart disease) caused by a non-coronary cusp sinus of Valsalva aneurysm with small perforation is reported. The aneurysm was causing ball valve obstruction at the tricuspid valve, leading to dilated right atrium and back pressure changes which were relieved after successful aneurysectomy.

Ball valve obstruction of a bronchus causing lobar emphysema in a neonate

Lobar emphysema in the neonate is usually congenital, resulting from cartilage deficiency causing bronchomalacia and distal air trapping. Acquired forms are usually associated with chronic lung disease or endobronchial obstruction such as mucus plugging. We report a pedunculated endobronchial polyp in a 2-month old ex-premature infant causing intermittent hyperinflation of the right middle lobe. The polyp was seen prolapsing in and out of the bronchus intermedius at bronchoscopy. Possible aetiological links with mechanical ventilation are discussed. We also emphasise the value of bronchoscopy prior to lobectomy in cases of congenital lobar emphysema (CLE).

Right Versus Left Double-Lumens for Left-Sided Thoracic Surgery

In Response: We appreciate the interest and comments of Dr. Schulman regarding our study (1). Benumof (2) recommends that the nonoperated mainstem bronchus should be routinely intubated because intubation of the operative mainstem bronchus may interfere with the performance of surgery. The “ball valve obstruction” suggested by Dr. Schulman, and described by others (3–4), leads us to believe that this may be another advantage of a right-sided double-lumen endotracheal tube (R-DLT) for left-sided thoracic surgery. We did not observe this problem in the 20 patients who received left-sided double-lumen endotracheal tubes (L-DLT) for left-sided thoracic surgery (1). Furthermore, we have not experienced this problem in our thoracic surgical practice overall–approximately 400 thoracotomy and thoracoscopic cases per year. Factors that should be considered before selecting a R-DLT for the “ball valve problem” include size of the tumor and proximity to the tracheal bifurcation or mediastinum. We advocate the use of a L-DLT for a left-sided thoracic surgery, unless there are contraindications to its use, for example, an exophytic lesion that causes compression of the left mainstem bronchus, intraluminal tumor that arises from the left main bronchus, tracheobronchial disruption, left-sided pneumonectomy, left lung transplantation, or a descending thoracic aortic aneurysm that compresses the left main bronchus. We believe that the “ball valve problem” is probably rare, but always should be considered when double-lumen endotracheal tubes and one-lung ventilation are planned. Javier H. Campos MD* Kemp H. Kernstine MD†

Right Versus Left Double-Lumens for Left-Sided Thoracic Surgery

In Response: We appreciate the interest and comments of Dr. Schulman regarding our study (1). Benumof (2) recommends that the nonoperated mainstem bronchus should be routinely intubated because intubation of the operative mainstem bronchus may interfere with the performance of surgery. The “ball valve obstruction” suggested by Dr. Schulman, and described by others (3–4), leads us to believe that this may be another advantage of a right-sided double-lumen endotracheal tube (R-DLT) for left-sided thoracic surgery. We did not observe this problem in the 20 patients who received left-sided double-lumen endotracheal tubes (L-DLT) for left-sided thoracic surgery (1). Furthermore, we have not experienced this problem in our thoracic surgical practice overall–approximately 400 thoracotomy and thoracoscopic cases per year. Factors that should be considered before selecting a R-DLT for the “ball valve problem” include size of the tumor and proximity to the tracheal bifurcation or mediastinum. We advocate the use of a L-DLT for a left-sided thoracic surgery, unless there are contraindications to its use, for example, an exophytic lesion that causes compression of the left mainstem bronchus, intraluminal tumor that arises from the left main bronchus, tracheobronchial disruption, left-sided pneumonectomy, left lung transplantation, or a descending thoracic aortic aneurysm that compresses the left main bronchus. We believe that the “ball valve problem” is probably rare, but always should be considered when double-lumen endotracheal tubes and one-lung ventilation are planned. Javier H. Campos MD* Kemp H. Kernstine MD†

Breath-holding—like spells in an infant: An unusual presentation of lingual thyroglossal duct cyst

The authors report the case of an infant with a lingual thyroglossal duct cyst who presented with breath-holding-like spells, which actually represented life-threatening ball-valve obstruction of the larynx, leading to hypoxemia and transient cerebral dysfunction. When evaluating apparent breath-holding spells in young infants, physicians should include dynamic, episodic upper airway obstruction in the differential diagnosis. J Pediatr Surg 35:1381-1384. Copyright © 2000 by W.B. Saunders Comapny.

A pedunculated papilloma causing ball valve obstruction of the larynx in a two‐year‐old child

Pediatric PulmonologyVolume 23, Issue 2 p. 117-119 Case Report A pedunculated papilloma causing ball valve obstruction of the larynx in a two-year-old child R. J. H. Massie MBBS (Hons), Corresponding Author R. J. H. Massie MBBS (Hons) Department of Respiratory Medicine, Royal Alexandra Hospital for Children, Camperdown, New South Wales, AustraliaDepartment of Respiratory Medicine, New Children's Hospital, Royal Alexandra Hospital for Children, PO Box 3515, Parramatta, NSW 2145, AustraliaSearch for more papers by this authorC. M. Mellis MD MPH, FRACP, C. M. Mellis MD MPH, FRACP Department of Respiratory Medicine, Royal Alexandra Hospital for Children, Camperdown, New South Wales, AustraliaSearch for more papers by this authorP. P. Van Asperen MD, FRACP, P. P. Van Asperen MD, FRACP Department of Respiratory Medicine, Royal Alexandra Hospital for Children, Camperdown, New South Wales, AustraliaSearch for more papers by this author R. J. H. Massie MBBS (Hons), Corresponding Author R. J. H. Massie MBBS (Hons) Department of Respiratory Medicine, Royal Alexandra Hospital for Children, Camperdown, New South Wales, AustraliaDepartment of Respiratory Medicine, New Children's Hospital, Royal Alexandra Hospital for Children, PO Box 3515, Parramatta, NSW 2145, AustraliaSearch for more papers by this authorC. M. Mellis MD MPH, FRACP, C. M. Mellis MD MPH, FRACP Department of Respiratory Medicine, Royal Alexandra Hospital for Children, Camperdown, New South Wales, AustraliaSearch for more papers by this authorP. P. Van Asperen MD, FRACP, P. P. Van Asperen MD, FRACP Department of Respiratory Medicine, Royal Alexandra Hospital for Children, Camperdown, New South Wales, AustraliaSearch for more papers by this author First published: 07 December 1998 https://doi.org/10.1002/(SICI)1099-0496(199702)23:2<117::AID-PPUL7>3.0.CO;2-MCitations: 1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume23, Issue2February 1997Pages 117-119 RelatedInformation

Pneumothorax due to Ball-Valve Obstruction of an Endotracheal Tube in a Mechanically Ventilated Patient

Barotrauma is a well-known complication of mechanical ventilation, thought to be related to alveolar rupture from localized hyperinflation. Mishaps related to endotracheal intubation can lead to barotrauma such as inadvertent intubation of the right mainstem bronchus. In this report, we describe pneumothorax as a consequence of ball-valve occlusion, a previously undescribed endotracheal tube malfunction.

Tension ball valve mucus plug in asthma

This report describes a patient with status asthmaticus and respiratory failure in whom profound hypoxemia developed during mechanical ventilation. During the hypoxemic episode, breath sounds were absent over the left lung, and chest radiography revealed a hyperlucent left hemithorax with tension shift of the mediastinum to the right. The presence of lung markings in the left lung on radiography eliminated the possibility of tension pneumothorax and led to the diagnosis of tension mediastinal shift secondary to a ball valve obstruction by a central mucus plug. Bronchoscopic lung lavage removed the mucus plug, thereby correcting the hypoxemia. Recognition of this previously undescribed acute complication of mechanical ventilation in status asthmaticus is essential so that confusion with tension pneumothorax is avoided and appropriate therapy instituted.

Prostatic Urethral Polyp Causing Lower Urinary Tract Obstruction: Report of a Case

Polyps of the male urethra are relatively uncommon lesions. They usually arise from the prostatic urethra mostly verumontanum or Just lateral to the verumontanum. Posterior urethral polyp often presents with hematuria, hemospermia and sometimes lower urinary tract obstruction. We recently experienced a pedunculated prostatic urethral polyp in a 63-year-old man who complained of gross total hematuria and difficult micturition for several years. On rectal examination the prostate was slightly enlarged with normal consistency. Excretory urogram showed a round filling defect in the right side of the bladder neck measuring about in size. Cystourethroscopy revealed trabeculation of the vesical wall, mild bilateral prostatic hypertrophy and a round cystic mass with a long stalk arising from the prostatic floor 1 cm. Proximal to the verumontanum which caused ball-valve obstruction in the bladder neck. This pedunculated polypoid mass was then resected at its base with resectoscope and was removed transurethrally using Lowsley's grasping forceps. The specimen was proved as fibrous polyp histologically.

Blood clot resulting in ball-valve obstruction in the airway

KRUCZEK, MICHAEL E. MD; HOFF, BRIAN H. MD; KESZLER, BERNEY R. MD; SMITH, R. BRIAN MD Author Information

Late Mucosal Ball Valve Obstruction of a Billroth I Anastomosis

Late Mucosal Ball Valve Obstruction of a Billroth I Anastomosis

Pneumothorax Secondary to Ball-valve Obstruction during Jet Ventilation

Pneumothorax Secondary to Ball-valve Obstruction during Jet Ventilation

PULMONARY HYPERINFLATION

Barotrauma has been used to describe several specific complications related to mechanical ventilation. These include tension lung cyst, pneumothorax, pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema. Pulmonary hyperinflation, another such complication, occurred in 6 patients, being fatal in 3. Two pathophysiologic mechanisms are discussed. The simpler, and well-recognized, ball-valve airway obstruction allows inspiration of air delivered by the mechanical ventilator but prevents expiration. A more complex circumstance exists when pulmonary contusion or infiltration produces differential lung compliances. This allows extreme hyperinflation of areas of normal lung during attempts to ventilate abnormal lung of low compliance. This mechanism is particularly evident when positive end-expiratory pressure (PEEP) is used in an attempt to open collapsed ventilatory units. Functional complications of lung hyperinflation include decreased alveolar ventilation and compression effects on adjacent structures. Interference with and shifts of regional lung perfusion may worsen gas exchange. Proper treatment includes airway clearance by bronchoscopy, the judicious use of bronchodilators, the discontinuance of PEEP, and adjustments of mechanical ventilators to prevent high airway pressures.