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SAEM Clinical Image Series: An Oropharyngeal Mass

Posted by Matthew Sherman, MD on

A fifty-year-old male presented to the emergency department (ED) unconscious with CPR in progress. Per EMS report, the patient was found down surrounded by emesis with no pulse or respirations. Fifteen minutes of CPR was performed prior to arrival in the ED with a King Tube in place. The King Tube was filled with emesis and increasingly difficult to bag. The King Tube was removed to attempt intubation and maximize oxygenation and ventilation.

When the Mac 4 blade was placed in the mouth, a large, pink, fleshy, and vascularized structure was seen in the mouth just anterior to where the uvula should have been located. Attempts were made to compress the mass into the tongue, separate the tongue from the mass, and sweep the mass out of the way. All attempts failed to expose the epiglottis. An attempt was made to remove the mass, but it appeared to be part of the mouth. The decision was made to proceed with a cricothyrotomy; a 6.0 tube was successfully placed, and the patient was able to be ventilated. Return of spontaneous circulation was never achieved and the patient expired in the ED.

Physical Exam

General: No signs of trauma, pulseless, apneic

HEENT: Large, fleshy, soft, vascularized mass obstructing the oropharynx

Labs

Glucose: 95 mg/dL

Case Question: What is this mass seen overlying the patient’s tongue?

The mass was identified as an esophageal polyp.

Per the autopsy report, an eleven-by-four-by-two-centimeter polypoid mass on a three-centimeter-long pedicle was found to originate from the upper esophagus. This mass completely obstructed the lumen of the larynx. Microscopic examination confirmed it was an esophageal polyp. The pathologist determined the cause of death to be asphyxia due to laryngeal obstruction by a lipomatous esophageal polyp. Esophageal polyps are rare tumors of the upper gastrointestinal (GI) tract [1-4]. They occur most commonly in middle-aged to elderly men [1].

Case Question: How would you proceed with an intubation if confronted with this situation?

In this case, early cricothyrotomy was key for ventilation and oxygenation, given the difficulty in displacing the mass to intubate. Patients are at severe risk of asphyxiation [3]. It is important to have a good difficult-airway algorithm; cricothyrotomy is not a failed airway.

The most common presenting symptom in patients with an esophageal polyp is dysphagia, but most polyps are small and patients can be asymptomatic [1-4]. While rare, there have been reported cases of syncope due to airway obstruction secondary to an esophageal polyp. It is important to recognize the potential for morbidity in patients who have polyps incidentally found on computed tomography (CT) scan [1].

Case Discussion

Take-Home Points

  • Lipomatous esophageal polyps are rare tumors of the GI tract but have high morbidity given their potential for regurgitation and subsequent airway obstruction.
  • A difficult airway algorithm is important; consider cricothyrotomy in cases with oral obstruction.

References

  • Feldman J, Tejerina M, Hallowell M. Esophageal lipoma: a rare tumor. J Radiol Case Rep. 2012;6(7):17–22. doi:10.3941/jrcr.v6i7.1015. PMCID: PMC3558046
  • Kau RL, Patel AB, Hinni ML. Giant Fibrolipoma of the Esophagus. Case Reports in Otolaryngology. 2012;2012:1-3. Doi:10.1155/2012/406167. PMCID: PMC3420783
  • Bak YT, Kim JH, Kim JG, et al. Liposarcoma arising in a giant lipomatous polyp of the esophagus. Korean J Intern Med. 1989;4(1):86–89. doi:10.3904/kjim.1989.4.1.86. PMCID: PMC4534968
  • Zhang H, Nie RH. A rare case of giant fibrovascular polyp of the esophagus. Saudi Med J. 2015;36(11):1348–1350. doi:10.15537/smj.2015.11.12531. PMCID: PMC4673374

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2020 SAEM Annual Meeting | Copyrighted by SAEM 2020 – all rights reserved. View other cases from this series on ALiEM.

Author information

Matthew Sherman, MD

Emergency Medicine Resident
University of Texas Southwestern Medical Center

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