Though more NGTS cases attributing to NGT have been reported, only two reports have shown NGTS induced by nasointestinal ileus tube except our case, [1-8] The proposed mechanisms is tissue injury caused by continuous pressure on the region of physiologic narrowing between hypopharynx and cervical esophagus. [2, 9, 10] Another possible mechanism would be a relationship between NGTS and gastroesophageal reflux due to supine position of the patient. [1, 11] First of all, appropriate therapy is immediate removal of tube to prevent the pressure induced by nasointestinal ileus tube. [5, 6, 12] In our study, the medication from early stage treatment was important because the mechanism of arytenoid edema would be caused by the infection from posterior cricoarytenoid muscle which was injured. [1, 9, 10] In addition, we speculate that the mechanism of vocal disfunction was a temporary paralysis induced by the reversible injure of posterior cricoarytenoid muscle because we could early recognize the laryngeal symptom. Clinical course; development of NGTS symptom during intubation and improvement of NGTS symptom after extubation, also shows that this case was a complication induced by NGT. There are several NGTS reports that the tube diameter is same size as 18 Fr in our case. [1, 2] It is suggested that a narrow tube diameter is better to be used, considering the mechanism. 
NGTS in our case developed three days after tube replacement, which is shorter than other report; the syndrome had been reported five days or more after tube placement. [1, 3, 6, 10, 13] However, there is a report that the symptom have developed within 12 hours after tube replacement.  Therefore, the thorosic symptom of hoarseness, wheezing in patients with the replacement of NGT should be payed attention due to a risk of acute deterioration in short duration. Especially, immunocompromised states have been reported to be risk factors for NGTS [2, 3, 13, 14] Usually, the nutritional status in patients with NGT or nasointestinal ileus tube deteriorates due to lack of oral intake. In our case, immunocompromised status was supposed because the physical findings and laboratory tests indicated the condition of malnutrition. In our case, the early detection and immediate treatment for NGTS could be performed without any sequelae. However, the symptom of NGTS potentially become severe in cases of tracheotomy, unfortunately death due to upper airway obstruction.  Thus, the condition of vocal cord and larynx should be examined carefully. A vocal paralysis associated with all NGTS is a most common observation confirmed by laryngoscope.  Immediately after suspicion of NGTS such as hoarseness and wheezing in patients with nasointestinal ileus tube, laryngoscopy is mandatory.  Nasointestinal ileus tube is usually used by gastroenterologists who are not used to medical assessment of larynx and pharynx. In addition, there are few reports about NGTS associated with nasointestinal ileus tube. Thus, NGTS associated with nasointestinal ileus tube is not known well.
Patients with nasointestinal ileus tube might be not able to appeal the symptom of NGTS immediately and accurately due to low ADL level or poor general condition as same as in our case. An early recognition of NGTS symptoms is important. In our case, an early recognition of hoarseness at NST round might avert a life-threatening condition of NGTS. Nasointestinal ileus tube is an effective treatment device on ileus.  A more narrow tube diameter will be ideally chosen to reduce the pressure against the organization.  However, thick tube diameter of nasointestinal ileus tube sometimes have to be used to treat ileus more effectively. [16, 17] Consequently, when nasointestinal ileus tube is used, systems for early diagnosis and proper management should be built in addition to wide knowledge for the presence of NGTS.
In conclusion, NGTS should be considered in patients not only with NGT but also with nasointestinal ileus tube. Early diagnosis and proper management for NGTS are important to prevent life-threatening case.