A 54-yr-old male with severe Barrett’s esophagus presented for endoscopic mucosal resection for treatment of high-grade esophageal dysplasia. This procedure involves the use of an endoscopic banding device to create a pseudopolyp following submucosal injection, allowing resection (with a snare) of the neoplastic lesion. The banding device is a modification of a device used for treatment of esophageal varices (wherein the varices are suctioned into the cap and the band is fired, leading to coagulative necrosis of the varix).

The patient’s airway examination showed adequate neck range of motion, adequate thyromental distance, and a Mallampati 2 view. Monitored anesthesia care was planned with intravenous fentanyl boluses and a propofol infusion. The patient initially did well; however, he later experienced a sudden inability to move air with a precipitous drop in oxygen saturations from 98% to 71%. Laryngospasm was suspected. Positive airway pressure was applied with a bag-mask device but was unsuccessful at terminating the event. Propofol and succinylcholine were administered, and the patient’s trachea was intubated easily by direct laryngoscopy. This resulted in immediate improvement in his oxygen saturations and air movement. During the intubation, the epiglottis appeared abnormal, and upon further examination, the mucosa on the lingual surface of the epiglottis showed that it had been inadvertently endoscopically banded (Figure A, arrow). The banding device has a two-way lock to prevent misfiring, but this likely malfunctioned, inadvertently fired during intubation of the esophagus, and snared the epiglottal mucosa. An otolaryngologist used forceps to remove the band without any apparent complication (Figure B). The patient’s trachea was extubated and he was discharged from the hospital that same day.

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figure 1

Epiglottis following endoscopy. A) Lingual surface of the epiglottis with a pseudopolyp created by an endoscopic ligation band (arrow). B) Lingual surface of the epiglottis following band removal

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Cardiopulmonary events cause up to 50% of the morbidity and mortality related to gastrointestinal endoscopy. The most common causes of respiratory failure during upper endoscopy are aspiration and drug-induced respiratory depression. Less frequently encountered respiratory complications include anaphylactic reactions, iatrogenic perforations, and mucosal damage during removal of foreign bodies. Tracheal compression from the endoscope or inadvertent endoscopic tracheal intubation may also lead to respiratory compromise. Procedural trauma to the epiglottis, as seen in this case, is an uncommon stimulus for laryngospasm and subsequent hypoxia during upper endoscopic procedures. Mortality following laryngospasm during upper endoscopy has been reported. In addition to expeditious management of laryngospasm, anesthesia personnel should consider the possibility of treatable and reversible iatrogenic causes of laryngospasm.