SESSION TITLE: Bronchology/Interventional Procedures Student/Resident Cases
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 07:30 AM - 08:30 AM
INTRODUCTION: Endobronchial ultrasound (EBUS) with fine needle aspiration biopsy is now the standard of care in lung cancer diagnosis and staging. The procedure is routinely performed under conscious sedation in a bronchoscopy suite. A convex-probe EBUS (CP-EBUS) scope has limited flexion and extension when compared to a regular bronchoscope. The scope is routinely inserted orally using a bite block. Laryngeal mask airway or endotracheal tube is required when the procedure is performed under general anesthesia. We here in report insertion of CP-EBUS through a tracheostomy tube without mechanical damage to the scope. Using this approach trans-bronchial fine needle aspiration biopsy of enlarged mediastinal lymph nodes can be safely performed in patients with closed upper airway by passing the CP- EBUS through a flexible tracheostomy tube.
CASE PRESENTATION: A 73-year-old woman presented to the emergency department with respiratory distress, throat pain and difficulty swallowing for four months. CT neck revealed a partially blocking laryngeal mass. Otolaryngology was consulted and she was emergently taken to the operating room for a tracheostomy. Biopsy of the supraglottic laryngeal mass, confirmed squamous cell carcinoma. Positron emission tomography scan performed for staging revealed enlarged mediastinal and hilar lymph nodes with increased Standardized Uptake Value. Pulmonary service was consulted for a trans-bronchial fine needle aspiration biopsy of the mediastinal and hilar lymph nodes. In order to safely insert the CP-EBUS bronchoscope into the airway, the fixed bend tracheostomy tube was changed to a flexible tracheostomy tube by otolaryngology. The procedure was successfully performed without mechanical damage to the scope.
DISCUSSION: CP-EBUS is a specialized bronchoscope that allows for identification and real time needle aspiration biopsy of lymph nodes and mediastinal structures located adjacent to the airway wall. Patients with cancer require careful preoperative staging to determine resectability and to initiate appropriate management. The sensitivity and specificity are high when performed by an experienced pulmonologist. It is mechanically difficult to insert the CP-EBUS scope through a tracheostomy tube as the ultrasound cannot pass through the bend of the tube. We describe a case of successfully inserting the CP-EBUS scope through a silicone flexible tracheostomy tube without any mechanical damage to the scope. Caution should be taken when changing a newly performed tracheostomy.
CONCLUSIONS: It is now possible to perform fine needle aspiration biopsy of enlarged mediastinal and hilar lymph nodes using CP-EBUS in patients with tracheostomy with upper airway obstruction.
Reference #1: Nakajima T, Yasufuku K, Yoshino I. Current status and perspective of EBUS-TBNA. General thoracic and cardiovascular surgery. 2013 Jul;61(7):390-6. PubMed PMID: 23436118
DISCLOSURE: The following authors have nothing to disclose: Bilal Jalil, Fuzail Ahmad Abdur Rahman, Ali Saeed
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