A 73-year-old man (168 cm, 59 kg) presented at our institution complaining of neck stiffness and dysphagia that had been slowly increasing over the last 2 years. He had been diagnosed with atrial fibrillation and stable angina, and undertook percutaneous coronary intervention (PCI) 6 months prior to the surgery. He had undergone anticoagulation therapy, which was changed to heparin 3 days before surgery. On physical examination, the patient was alert and afebrile; and his vital signs were stable. Oral examination was unremarkable. Blood chemistry revealed no remarkable findings. Heparin was discontinued at preoperative midnight. Lateral radiography of the cervical spine demonstrated extensive osteophyte formation from C2 to C4 (Fig. 1A). A preoperative neck computed tomography (CT) revealed slight narrowing of the airway at the level of epiglottis, a finding compatible with Forestier's disease. General anesthesia was induced with thiopental sodium 250 mg and rocuronium 50 mg and endotracheal tube was inserted with lightwand without difficulty. The intraoperative findings using an anterolateral transverse approach included a hard bony mass at the level of C2-4 and compression of the esophagus and trachea. Decompression of the osteophyte was performed with a drill for 135 minutes. The patient was transferred to the postanesthetic care unit (PACU) following the operation. In the PACU the endotracheal tube was removed after full assessment of consciousness and muscle power. The patient was transferred to the general ward and had no complaints until 6 hour after the completion of surgery. At that time, patient complained of dyspnea and sudden respiratory compromise and cardiac arrest were developed. Emergent endotracheal tube insertion was attemped but the hypopharyngeal structure could not be identified because of severe laryngeal edema. Emergency tracheostomy was done with an ID 7.0 tube. With the impression of postoperative bleeding, emergent surgery was arranged. However, there was no bleeding at the operative site. Instead, the connective tissue and mucosa were severely edematous. Lateral radiography of the cervical spine demonstrated extensive soft tissue edema and airway narrowing (Fig. 1B). There was no evidence of remaining osteophyte. The patient's brain was damaged and discharged with serious neurologic sequelae.

A 74-year-old male patient (168 cm, 53 kg) visited our institution complaining of difficulty in swallowing for the past 8 years and the frequent occurrence of aspiration pneumonia for the past 1year. Lateral radiography of the cervical spine demonstrated extensive osteophyte formation from C2 to C4 (Fig. 2) and decompression of the osteophyte was planned. His medical history was significant for diabetes. He had been diagnosed with stable angina but rejected PCI. Preoperative electrocardiogram and echocardiogram revealed tolerable status. Blood chemistry revealed hyperglycemia, but hepatic and renal function and coagulation were normal. On physical examination, the patient was alert and afebrile; and his vital signs were stable. Oral examination was unremarkable and neck extension was normal. He had minimal dyspnea in the supine position. Indirect laryngoscopy revealed a large hard mass protruding from the posterior wall of the hypopharynx that concealed the arytenoids cartilage (Fig. 3A). A preoperative neck CT showed slight narrowing of the airway at the level of the epiglottis. Vocal fold mobility was preserved. No narrowing of the subglottic region was observed when flexible endoscopy was performed. Preoperative tracheostomy was done under local anesthesia and general anesthesia was induced with thiopental sodium 250 mg and rocuronium 50 mg and maintained with sevoflurane. Complete decompression of the osteophyte was performed for 210 minutes using an anterolateral transcervical approach, which proceeded without any complications. The postoperative course was uneventful. On the second postoperative day, indirect laryngoscopy was performed by an otolaryngologist to decide if removal of the tracheostomy cannulawas appropriate. However, this examination revealed significant laryngeal edema including the epiglottis and posterior laryngeal wall (Fig. 3B). On 29th postoperative day, flexible endoscopic examination was performed again and copious secretion, decreased vocal cord mobility and narrowing of the upper airway were observed (Fig. 3C) and the patient was discharged on the 33^rd postoperative day with a double cannula having a speech valve. On the 59th postoperative day, the tracheostomy cannula was removed (Fig. 3D) at the outpatient clinic without any complication.