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Retrieval of a Esophageal pH Monitoring Probe Dislodged Into the Laryngopharynx: A Case Report

Kristobak, Benjamin M. MD; Crane, Kathryn A. MD

doi: 10.1213/XAA.0000000000000961
Case Reports
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Esophageal pH monitoring via wireless probes is used to evaluate chest pain and atypical symptoms and diagnose gastroesophageal reflux. These probes are commonly placed during esophagogastroduodenoscopy performed by gastroenterologists in an ambulatory anesthesia setting. Dislodgment and aspiration of these probes can cause morbidity, require surgical removal, and involve the anesthesia provider in prolonged emergency care. We present a case of a probe dislodgment where aspiration was avoided and describe how retrieval of this device is different from typical hypopharyngeal foreign body removal.

From the Anesthesia Service, Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland.

Accepted for publication December 6, 2018.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website.

Address correspondence to Benjamin M. Kristobak, MD, Department of Anesthesia, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889. Address e-mail to kristobak.ben@gmail.com.

Wireless esophageal pH monitors, commercially marketed as the Bravo Probe (Bravo; Medtronic, Shoreview, MN), are used to correlate the patients’ symptoms with gastroesophageal reflux disease.1,2 The device is 6 mm × 5.5 mm × 25 mm, and constructed of hard plastic. It is attached to the esophageal mucosa by vacuum 5–6 cm above the lower esophageal sphincter under endoscopic guidance.3 This procedure is commonly performed during esophagogastroduodenoscopy and monitored anesthesia care.4 Typical complications associated with wireless pH monitoring probes are similar to those seen in capsule endoscopy and include chest pain, dysphagia, foreign body sensation, nose and throat pain, coughing, headache, abdominal pain, nausea, and vomiting.5 We present a case of a probe dislodgment during esophagogastroduodenoscopy under monitored anesthesia care where intubation minimized the risk of aspiration and facilitated removal without surgical consultation.

The patient provided written consent for publication of a case report.

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CASE DESCRIPTION

A 59-year-old woman with chronic back pain, opioid dependence, atypical gastroesophageal reflux disease without frank reflux, and gastric ulcers without Helicobacterpylori infection presented for esophagogastroduodenoscopy. The patient was nulla per os >8 h. Monitored anesthesia care was provided with a lidocaine bolus and propofol infusion. The patient had a prominent gag reflex and deep sedation was required to allow placement and removal of the endoscope. A wireless pH monitoring probe was placed in the patient’s esophagus 6 cm above the lower esophageal sphincter. On withdrawal of the endoscope to confirm proper probe placement, the probe was not visualized (Figure 1). It was not found in the stomach or duodenum and the endoscope was removed to view the laryngeal pharynx. The probe was found in the pyriform fossa near the glottic opening (Figure 2). Multiple unsuccessful attempts were made to retrieve the device using Magill and endoscope forceps under endoscopic visualization. These techniques moved the probe closer to the glottic opening than seen in Figure 2.

Figure 1.

Figure 1.

Figure 2.

Figure 2.

Further attempts to remove the probe risked displacing it into the trachea. Otolaryngology consultation would delay probe removal, create a window of opportunity for probe migration into the trachea during the wait, and may have required transfer of the patient to an operating room. The patient was placed in the Trendelenburg position; general anesthesia was induced with additional propofol and succinylcholine; and an endotracheal tube was placed using a video laryngoscope. Once endotracheal intubation eliminated the risk of passage of this hard, small foreign body into the trachea, Magill forceps were used to remove the device from the laryngopharynx without trauma to the pharynx or glottis (Supplemental Digital Content, Video 1, http://links.lww.com/AACR/A247). After emergence, the patient’s airway was suctioned and the trachea extubated. The procedure time was only extended by about 10 minutes because of these interventions.

The patient was allowed to recover in the postanesthesia care unit for an additional hour before discharge home. The patient described a mild sore throat as expected from laryngoscopy and intubation, but reported no hoarseness, dysphagia, coughing, or myalgia from succinylcholine.

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DISCUSSION

Dislodgment of a wireless pH monitoring probe has been discussed in gastroenterology endoscopic literature,6,7 but not anesthesiology literature. Most often, dislodged probes travel down the gastrointestinal tract and are of little consequence. However, tracheal aspiration of a hard foreign body can lead to laryngeal, tracheal, and bronchial damage, bronchospasm, pneumothorax, or pneumonia.8 Haseeb et al6 describe immediate intubation, positive pressure ventilation, transfer to another facility, and ridged bronchoscopy. Even if these injuries and sequelae do not occur, expert surgical assistance may be needed to remove the device from the oropharynx or trachea. In Kumar et al’s7 case, the patient was intubated, transferred to an operating theater, and surgical consultation was obtained, even though the probe was not aspirated into the trachea. These interventions are difficult or impossible to accommodate in an ambulatory care center with a busy procedure schedule. Even in a large hospital setting, urgent consultation and transport to an operating theater can put the patient at increased risk of morbidity and delay the care of other patients. There may be delays and lost revenue for the endoscopist, anesthesia provider, and the facility.

The video laryngoscope is a useful tool in addressing difficult airways and has been shown to provide optimal visualization for the removal of hypopharyngeal foreign bodies.9–13 Morris et al9 described the use of a video laryngoscope to remove hypopharyngeal foreign bodies in the operating room. They point out that given the curvature of the GlideScope (Verathon Inc, Bothell, WA) handle, foreign bodies can frequently be removed under conscious sedation, unlike direct laryngoscopy which often requires general anesthesia, intubation, and muscle paralysis.9 It is common for otolaryngologists to remove foreign bodies in this manner without first intubating the patient. Likewise, our first attempts at removing the probe were before intubating the patient.

The present case differs from reported use of video laryngoscopy to remove pharyngeal foreign bodies in a few key ways. In many reported cases, the foreign body is larger than a esophageal pH probe9,10 and easier to grasp. Smaller objects become dislodged into the hypopharynx as described by Cagini et al.11 These patients present to emergency departments and clinics with impacted hypopharyngeal foreign bodies. This impaction ensures that the foreign body is unlikely to move and be aspirated. If the foreign body was not impacted, it would have been either coughed out or aspirated by the time of presentation. In these cooperative patients who are at low risk for foreign body aspiration, topical anesthesia can be used.9,11 Finally, while nosocomial foreign body dislodgment and removal with a video laryngoscope have been described,12 it has always been addressed with otolaryngologists in an operating room environment rather than a lone anesthesiologist in an ambulatory care setting.

Esophageal pH probe dislodgment in a sedated and uncooperative patient presents a risk of aspiration of a small, hard foreign body that is not impacted, and is therefore free to move into the trachea. At the same time, the patient is sedated and has decreased airway reflexes. It has been shown that spontaneously breathing patients receiving propofol or sevoflurane have impaired coordination between swallowing and ventilation.13 Hypercapnia also likely plays a role in impairment of pharyngeal clearance. A higher rate of pathologic swallows in conjunction with an increased ventilatory drive can make aspiration of the probe into the trachea more likely.13 These findings were also described in patients receiving midazolam or morphine for sedation.14 Gemma et al15 showed that even when targeting drug levels for deep sedation, swallowing and pharyngeal clearance were impaired. Increasing age and body mass index also correlate with pathologic swallowing in the setting of deep sedation.

Transporting a deeply sedated and unintubated patient to the operating room for surgical removal of the foreign body requires either decreasing anesthesia for transport, which may lead to coughing and ventilatory distress, or possibly increasing the risk of aspiration. For this reason, while intubation is not required, it should be considered to eliminate the risk of aspiration in sedated patients with small, nonimpacted foreign bodies, in patients unable to cooperate during topical anesthesia of the airway, or in situations in which delay can lead to aspiration. Adequate equipment, specifically a video laryngoscope and Magill forceps, must be immediately available.

To our knowledge, this is the first report of removal of esophageal pH probe by anesthesiologists and is the first case where aspiration of a nosocomial foreign body was avoided using a video laryngoscope. Given the frequency of endoscopic procedures, displacement of these probes, while unusual, are increasingly likely to occur in ambulatory anesthesia populations. It is important that anesthesiologists become aware of this potential complication and the unique features of its presentation.

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ACKNOWLEDGMENTS

The authors thank Dr Stephen Curtis, MD, of Walter Reed National Military Medical Center Gastroenterology Service, Bethesda, MD, for his assistance in obtaining the endoscopic images for this report. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.

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DISCLOSURES

Name: Benjamin M. Kristobak, MD.

Contribution: This author helped supervise the case, review the literature, and write and edit the manuscript.

Name: Kathryn A. Crane, MD.

Contribution:

This author helped perform the case, review the literature, and edit the manuscript.

This manuscript was handled by: Raymond C. Roy, MD.

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REFERENCES

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3. Lawenko RM, Lee YY. Evaluation of gastroesophageal reflux disease using the Bravo capsule pH system. J Neurogastroenterol Motil. 2016;22:25–30.
4. Patel R, Chae S, Kumar A, Richter JE. Sedation and afternoon placement of the 48-hour wireless ambulatory pH capsule results in more reflux on the first day. J Clin Gastroenterol. 2017;51:594–598.
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12. Ho G, Singh N, Andrews J, Westhead P. Novel use of videolaryngoscopy to remove a foreign body. [published online July 7, 2015] BMJ Case Rep 2015. doi: 10.1136/bcr-2015-210011.
13. D’Angelo OM, Diaz-Gil D, Nunn D, et al. Anesthesia and increased hypercarbic drive impair the coordination between breathing and swallowing. Anesthesiology. 2014;121:1175–1183.
14. Hårdemark Cedborg AI, Sundman E, Bodén K, et al. Effects of morphine and midazolam on pharyngeal function, airway protection, and coordination of breathing and swallowing in healthy adults. Anesthesiology. 2015;122:1253–1267.
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