A case of unusual choking

Q; 65-year-old female was admitted to ICU 9 days ago with small bowel obstruction. Pt. is now stable and about to get transferred out of the unit. The patient suddenly starts complaining of a choking sensation with two hands on the neck. The monitor shows oxygen desaturation. The patient was intubated emergently. No laryngeal or vocal edema was seen on the laryngoscope, but vocal cord paralysis was noted.

Answer; Nasogastric tube syndrome

Nasogastric tube syndrome was described about 25 years ago by Sofferman and Coll. It is a life-threatening complication of an indwelling (more than a week) nasogastric tube. The syndrome may present as complete vocal cord abductor paralysis. The syndrome is thought to result from perforation of the NG tube-induced esophageal ulcer and infection of the posterior cricoid region (postcricoid chondritis) with subsequent dysfunction of vocal cord abduction. Unilateral paralysis of the cord is also described. Treatment includes the protection of the airway, removal of NG tubes, and the use of antibiotics. Some advocate antireflux therapy, too. Another variant is described as having no esophageal ulcer but possibly because of ischemia of the laryngeal abductor muscle secondary to physical compression of the postcricoid blood vessels by NG tube.

The bigger the size, the higher the chances of NGT syndrome.

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References: 

1. Apostolakis LW, Funk GF, Urdaneta LF, McCulloch TM, Jeyapalan MM. The nasogastric tube syndrome: two case reports and review of the literature. Head Neck. 2001 Jan;23(1):59-63. doi: 10.1002/1097-0347(200101)23:1<59::aid-hed9>3.0.co;2-a. PMID: 11190859.

  

2. Isozaki E, Tobisawa S, Naito R, Mizutani T, Hayashi H. A variant form of nasogastric tube syndrome. Intern Med. 2005 Dec;44(12):1286-90. doi: 10.2169/internalmedicine.44.1286. PMID: 16415551.

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3. Taira K, Koyama S, Morisaki T, Fukuhara T, Donishi R, Fujiwara K. Nasogastric Tube Syndrome: A Severe Complication of Nasointestinal Ileus Tube. Case Rep Gastroenterol. 2023 Apr 13;17(1):191-196. doi: 10.1159/000526715. PMID: 37261032; PMCID: PMC10228247.

  

4. Sano N, Yamamoto M, Nagai K, Yamada K, Ohkohchi N. Nasogastric tube syndrome induced by an indwelling long intestinal tube. World J Gastroenterol. 2016 Apr 21;22(15):4057-61. doi: 10.3748/wjg.v22.i15.4057. PMID: 27099450; PMCID: PMC4823257.

5. Sofferman, R.A. and Hubbell, R.N., "Laryngeal Complications of Nasogastric Tubes," ANNALS OTOLOGY, RHINOLOGY, AND LARYNGOLOGY, 90:465-468, 1981.