Acute Endotracheal Tube Obstruction and Airway Bleeding from an Avulsed Presumed Upper-Airway Mucosal Tag Following Difficult Intubation: A Case Report

Introduction: Airway bleeding alongside sudden peak airway pressure rise following endotracheal intubation is uncommon. In patients with a recent history of thrombocytopenia, a hematological cause may be misattributed. This case highlights a presumed avulsed upper-airway mucosal tag as an under-recognized cause of airway bleeding and obstruction. Case Summary: A 61-year-old woman with ovarian carcinoma, recently treated for thrombocytopenia, with a normalized platelet count preoperatively, underwent difficult intubation for debulking surgery. Shortly after ventilation began, blood appeared in the endotracheal tube, with rise in peak airway pressures. Flexible bronchoscopy identified a presumed avulsed upper-airway mucosal tag obstructing the endotracheal tube. Removal of the tissue and exchange of the endotracheal tube led to normalization of airway pressures and resolution of bleeding. Postoperative airway examination showed mild erythema and the patient had an uncomplicated postoperative course. Conclusion: Acute airway bleeding accompanied by raised peak airway pressures following intubation should prompt early bronchoscopy to exclude mechanical obstruction, even when a hematological cause coexists.