[Case of pharyngeal emphysema with airway obstruction during retroperitoneal laparoscopic nephroureterectomy]

A 76-year-old woman with right renal pelvic cancer underwent a laparoscopic nephroureterectomy via a retroperitoneal approach. During the 300 minutes of CO2 insufflation, arterial blood pressure, temperature, and oxygen saturation were stable, whereas the end-tidal CO2 (ETCO2) gradually increased and reached a peak of 55 mmHg. Her arterial blood gas analysis suggested acute respiratory acidosis. She developed hypercapnia in spite of controlled hyperventilation in response to the increasing ETCO2. Skin crepitus was extending into the neck and face from the operative site. A portable chest radiograph taken postoperatively showed pneumomediastinum and extensive subcutaneous emphysema of neck and chest wall. Laryngoscopy revealed grossly emphysematous pharyngeal tissues preventing direct vocal cord visualization. Her airway was appeared to be totally occluded by markedly edematous laryngeal tissues. As a leak sound around the tracheal tube was not heard after deflation of the tube cuff, her pharyngeal swelling was suspected to be severe and tracheal extubation during the operation was postponed. When cervicofacial emphysema occurs intraoperatively, we recommend that laryngoscopy should be performed before tracheal extubation to avoid potential airway obstruction from associated pharyngeal emphysema.