Background: Unexpected airway obstruction in the peri-extubation period can result in significant morbidity and may be caused by rare, unrecognized laryngeal pathologies. Negative-pressure pulmonary edema (NPPE) is a serious complication of acute upper airway obstruction and may progress to acute respiratory distress syndrome (ARDS) if severe or prolonged.
Case Presentation: A 35-year-old obese female with a history of childhood poliomyelitis who underwent elective lumbar decompression and fusion surgery under general anesthesia. Preoperative assessment revealed multiple predictors of difficult airway, including Mallampati grade IV, short neck, and restricted neck mobility. Mask ventilation and tracheal intubation were difficult but successfully managed intraoperatively. The patient was extubated after fulfilling standard criteria; however, within one hour postoperatively, she developed acute respiratory distress with inspiratory stridor and rapid desaturation. Despite initial supportive measures, hypoxemia persisted, necessitating re-intubation. Chest radiography revealed bilateral diffuse alveolar infiltrates with a normal cardiac silhouette, consistent with non-cardiogenic pulmonary edema. The clinical course progressed to severe hypoxemic respiratory failure fulfilling criteria for ARDS, requiring invasive mechanical ventilation with high positive end-expiratory pressure and 100% inspired oxygen. Subsequent laryngoscopic evaluation revealed idiopathic bilateral vocal cord abductor palsy. This case highlights a rare and life-threatening sequence of perioperative events wherein unrecognized bilateral vocal cord abductor palsy led to acute airway obstruction, NPPE, and ARDS. Early recognition of post-extubation respiratory distress, prompt airway control, and aggressive supportive management are essential to prevent progression and ensure favorable outcomes.
Keywords: Difficult airway; Bilateral vocal cord abductor palsy; Negative-pressure pulmonary edema; Acute respiratory distress syndrome; Post-extubation airway obstruction; Laryngospasm; Mechanical ventilation; High positive end-expiratory pressure; Non-cardiogenic pulmonary edema
How to cite this article: Kedareshvara KS, Arun PR, Mishra R, The Airway That Refused To Open: A Case Report Of Idiopathic Bilateral Vocal Cord Abductor Palsy Complicated By Negative-Pressure Pulmonary Edema And Acute Respiratory Distress Syndrome. Int J Drug Deliv Technol. 2026;16(4s): 197-203; DOI: 10.25258/ijddt.16.197-203