SESSION TITLE: Airway Cases I
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 27, 2013 at 07:30 AM - 08:30 AM
INTRODUCTION: Endoscopic management of tracheal stenosis has been shown to be successful. However, the utility of this approach in complete obstruction is unknown. We present a case of complete tracheal stenosis successfully treated using flexible bronchoscopy (FB) and retrograde transillumination.
CASE PRESENTATION: A 40-year-old male, with a history of prolonged mechanical ventilation and tracheostomy following a motorcycle accident, presented for treatment of complete suprastomal tracheal obstruction after previously refusing surgical resection-anastomosis. Physical examination was unremarkable except for a tracheostomy tube. FB revealed 100% occlusion of the trachea 3-cm below the vocal cords. A second bronchoscope was inserted through the tracheostomy stoma and advanced in a retrograde fashion towards the vocal cords. With the lamp turned off on the first bronchoscope, distal tracheal lumen was identified with transillumination. A 19G Wang needle was first inserted from above to create a small opening. Argon plasma coagulation and balloon dilation were subsequently used to enlarge the orifice. Post-procedure, the tracheal lumen was 50% of normal size. Repeat FB four weeks later showed granulation tissue with 90% stenosis; cryotherapy and balloon dilation were performed. Post-procedure, the lumen size was more than 50% of normal, and he was able to speak with occluding the tracheostomy. He has since required several follow-up bronchoscopic interventions. He continues to speak with the aid of a speaking valve on a fenestrated tracheostomy tube after six months and has had subjective improvement in his overall quality of life.
DISCUSSION: Successful treatment of total tracheal obstruction has previously been described using rigid bronchoscopy, retrograde transillumination, and T-tube or stent placement. Differing from this approach, we opted to use dual FB. We were able to successfully achieve airway patency without a stent placement and he regained his ability to speak utilizing this approach with a combination of interventional modalities. We feel that retrograde transillumination contributed to the success of this procedure and provided an added measure of safety by identifying and allowing direction of intervention towards the tracheal lumen. Retrograde transillumination will be a useful adjunct in the bronchoscopic management of complete tracheal stenosis. We describe the first case of its use in conjunction with flexible bronchoscopy.
CONCLUSIONS: This case illustrates the potential for FB in the treatment of complete tracheal stenosis. Retrograde transillumination allows for a safe endobronchial approach.
Reference #1: Vandemoortele, T et al. Endobronchial Treatment of Complete Tracheal Stenosis: Report of 3 Cases and Description of an Innovative Technique. Ann Thorac Surg. 2013; 95: 351-354
DISCLOSURE: The following authors have nothing to disclose: Douglas Closser, Shaheen Islam
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