Correspondence

[9] Agostoni M, Fanti L, Gemma M, Pasculli N, Beretta L, Testoni PA.

Adverse events during monitored anesthesia care for GI endoscopy: an
8-year experience. Gastrointest Endosc 2011;74:266-75.
[10] Ihra G, Gockner G, Kashanipour A, Aloy A. High-frequency
jet ventilation in European and North American institutions:
developments and clinical practice. Eur J Anaesthesiol 2000;17:
418-30.
[11] Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway
Society guidelines for management of the unanticipated difficult
intubation. Anaesthesia 2004;59:675-94.
[12] Wei HF. A new tracheal tube and methods to facilitate ventilation and
placement in emergency airway management. Resuscitation 2006;70:
438-44.
[13] Rezaie-Majd A, Bigenzahn W, Denk D, et al. Superimposed
high-frequency jet ventilation (SHFJV) for endoscopic laryngotracheal surgery in more than 1500 patients. Br J Anaesth 2006;
96:650-9.

A ruptured pheochromocytoma: an
unlikely cause of Brown-Sequard syndrome
To the Editor:
A 56 year old woman with severe angina was taken to a
local community hospital. Her past medical history was
significant for uncontrolled hypertension (currently taking
three antihypertensives), deep venous thrombosis, and a
descending aortic aneurysm. Computed tomography (CT)
showed a retroperitoneal bleed. The decision was made to
emergently transfer her to a tertiary-care center for her
persistent tachycardia and hypotension. En route, she
arrested, was resuscitated, and was transfused blood products
on arrival in preparation for the operating room. The patient
underwent an emergent exploratory laparotomy, but later
required an interventional radiology procedure to embolize
the retroperitoneal bleed.
Her intensive care unit stay was complicated by
abdominal compartment syndrome, ischemic bowel, as
well as pneumonia. Six weeks after her initial insult, her
mental status improved, but she had lower extremity
weakness, which was later attributed to Brown-Sequard
syndrome. This was thought to be secondary to spinal cord
ischemia, which likely occurred during her cardiac arrest.
She underwent serial CT scans of the abdomen to evaluate
for resolution of the retroperitoneal bleed, which showed a
right-sided pheochromocytoma. After 8 weeks, she was
discharged to a rehabilitation facility and was started on an
alpha-blocker, phenoxybenzamine, to control her hypertension. She underwent resection of the pheochromocytoma as
well as an ileostomy takedown one year after her inciting
event; her diagnosis was confirmed by pathology. The
patients surgery and recovery were both uneventful and she
was discharged home.
This patient might have benefited from further workup of
her uncontrolled hypertension. Her severe hypertensive
episode precipitated a major retroperitoneal bleed, leading
to spinal cord ischemia, resulting later in a diagnosis of
Brown-Sequard syndrome. This syndrome may be secondary

159
to a spinal cord tumor, ischemia, infectious or inflammation,
multiple sclerosis, or trauma/stabbing. Retroperitoneal
bleeding secondary to pheochromocytoma rupture has not
been well documented [1,2]. There was a case report of
Brown-Sequard syndrome in conjunction with a pheochromocytoma, but the neurological deficit was attributed to a
metastasis of the malignancy [3,4].
While pheochromocytoma comprises only 0.1% of cases
of hypertension, it should be included in the differential
diagnosis for severe hypertension, especially if multiple
antihypertensives are unable to control blood pressure
adequately [5]. While there is some controversy with
current recommendations of whether or not to start alphablockers preoperatively, the cornerstone of management
has been to start these medications preoperatively for blood
pressure control, and to diminish responses to catecholamine secretion. Alpha blockers should be started two
weeks preoperatively to restore intravascular volume; they
should also be started prior to the addition of beta blockers
to avoid precipitating congestive heart failure. Given the
extensive cardiac changes that may occur, it is advisable
to obtain an echocardiogram to further assess cardiac
function. General anesthesia with or without regional
technique has been used [5,6]. Continuous blood pressure
monitoring is required, as well as both vasodilators or
vasopressors to manage hemodynamic changes. Continuous
infusions of phentolamine or sodium nitroprusside may be
used for hypertension intraoperatively [5]. While postoperative hypotension is possible, it is less likely with adequate
volume resucitation and preoperative treatment with alpha
blockers [5]. Lastly, ischemic complications such as BrownSequard syndrome, while rare, may be seen in the
postoperative period. In an emergent setting, vigilance is
key; both hypertension as well as hypotension may be
problematic and preparation for massive hemorrhage
is required.
Megha Karkera MD (Fellow)
Department of Anesthesiology
University of Arkansas for Medical Sciences
Little Rock, AR 72205, USA
E-mail address: mmkarkera@uams.edu
http://dx.doi.org/10.1016/j.jclinane.2013.10.008

References
[1] Hayashi T, Nin M, Yamamoto Y, et al. Pheochromocytoma with
retroperitoneal hemorrhage after abdominal trauma. Hinyokika Kiyo
2009;55:703-6.
[2] Ito K, Nagata H, Miyahara M, Saito S, Murai M, Narimatsu Y.
Embolization for massive retroperitoneal hemorrhage from adrenal
pheochromocytoma: a case report. Hinyokika Kiyo 1997;43:
571-5.
[3] Habib M, Tarazi I, Batta M. Arterial embolization for ruptured adrenal
pheochromocytoma. Curr Oncol 2010;17:65-70.

160

Correspondence

[4] Miyamori I, Yamamoto I, Nakabayashi H, Takeda R, Okada Y.

Malignant pheochromocytoma with features suggesting the BrownSquard syndrome. A case report. Cancer 1977;40:402-55.
[5] Kerr GE, Fontes ML. Pheochromocytomas. In: Yao FSF, Fontes M,
Malhotra V (editors). Yao and Artusios Anesthesiology ProblemOriented Patient Management. 6th ed. Philadelphia; Lippincott
Williams & Wilkins; 2008. P. 77580.
[6] Myklejord DJ. Undiagnosed pheochromocytoma: the anesthesiologist
nightmare. Clin Med Res 2004;2:59-62.

Intubation difficulties in a patient with

an esophageal foreign body
To the Editor:
Anesthesia providers are occasionally called to care for
patients with an obstructed esophageal foreign body.
Although anesthetic management is relatively straightforward, one might be surprised with airway challenges due to
the location of the foreign body. We describe an
unexpected airway difficulty experienced during the course
of an anesthetic.
A 42 year old man presented for an emergency
esophagoduodenoscopy to remove a possible impacted
food bolus. The patient was eating barbecued chicken in a
hurry at a street festival the night before, when the meat
was thought to have become lodged in his upper throat.
He experienced immediate dysphagia to liquids, including
his saliva. Nasopharyngeal laryngoscopy performed by an
otorhinolaryngologist was negative. There was no stridor,
although throat discomfort was less apparent when the
patient was in the supine position than when he was
sitting up.
General examination was uneventful with normal observations, and blood tests were unremarkable. Airway
examination showed a limited mouth opening (Mallampati
grade 4), with full flexion and extension of the neck. A plan
was made to provide general endotracheal anesthesia. Rapidsequence induction with propofol and succinylcholine was
followed by an attempted intubation with a GlideScope
(Verathon, Bothell, WA, USA) video laryngoscope. Although the vocal cords were easily visualized, difficulty was
experienced in advancing the endotracheal tube (ETT)
beyond a certain point. No foreign body was visible in the
oropharynx. The GlideScope was removed and the ETT was
connected to a breathing system. Ventilation was easy and a
normal capnogram was present.
However, we noticed that the 21 cm mark of the ETT was
at the level of the patient's lip. An attempt was made to
deflate the cuff and advance the ETT further, which was
unsuccessful. A second similar attempt failed to achieve
further ETT advancement. With awareness of the risks of
esophageal perforation with persistent attempts, we proceeded with insertion of a gastroscope. Anesthesia was
maintained with supplemental propofol and sevoflurane. On
insertion of the gastroscope, the ETT cuff was readily visible
in the throat [Fig. 1]. The Gastroenterology Fellow had

Fig. 1 Cuff of the endotracheal tube visible during insertion of

the gastroscope.

difficulty in advancing the gastroscope. However, the

attending advanced the gastroscope into the esophagus
with some difficulty. In the process of this action, the food
bolus was pushed further into the midesophagus. The
chicken fragment was removed in a single piece using
endoscopy forceps [Fig. 2]. Eosinophilic esophagitis features
were noticed and the endoscope was removed. The ETT
cuff was deflated and the tube was easily advanced and
secured at the lip at the 23 cm mark after confirmation of
bilateral air entry.
In young adults, food impaction in the esophagus is usually
associated with eosinophilic esophagitis. In a large series of 43
consecutive adults presenting with food impaction, the
cricopharyngeal region was involved in two patients [1].
Although rare, one has to consider the possibility of difficult

Fig. 2

Chicken piece impacted in the upper esophagus.