Images in anesthesiology: Fatal airway obstruction caused by a ball-valve laryngeal polyp

Laryngeal polyps are common benign lesions typically located at the vocal cord junction of the anterior and middle thirds, arising from chronic irritation or trauma. Contributing factors include vocal strain, smoking, vaping, environmental irritants, and laryngopharyngeal reflux. These polyps often cause hoarseness, dysphonia, and occasionally dyspnea. Large pedunculated polyps present a significant risk as they can prolapse into the glottis or trachea, causing dynamic airway obstruction through a “ball-valve effect,” which may result in life-threatening respiratory distress. Emergency airway management, such as awake tracheostomy, is critical in such cases to secure the airway and avoid exacerbating edema or bleeding. Here, we report a case of the ball-valve effect of a large pedunculated laryngeal polyp, with near-complete airway obstruction during inspiration and resolution during expiration. Management of these polyps often require surgical resection, necessitating careful anesthetic management, particularly in obese or anxious patients. Preoperative evaluation and a multidisciplinary approach involving anesthesiologists and otolaryngologists are essential to ensure effective and safe airway management. Awake fiberoptic intubation with pediatric bronchoscope and reinforced small diameter endotracheal tube is often an anesthetic management of choice. In urgent or severe cases, large polyps may cause acute airway obstruction, presenting with symptoms such as stridor, severe respiratory distress, or cyanosis. Without prompt intervention, these events can lead to catastrophic outcomes, including sudden death. Emergency airway interventions, such as awake tracheostomy is critical in these scenarios. Preventive measures, including smoking cessation, avoiding vaping, and voice therapy, are vital for long-term care and reducing recurrence risk.