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 patient’s 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: [email protected] 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.

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[4] Miyamori I, Yamamoto I, Nakabayashi H, Takeda R, Okada Y. Malignant pheochromocytoma with features suggesting the BrownSéquard 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 Artusio’s Anesthesiology ProblemOriented Patient Management. 6th ed. Philadelphia; Lippincott Williams & Wilkins; 2008. P. 775–80. [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.

A ruptured pheochromocytoma: an unlikely cause of Brown-Sequard syndrome.

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