Department of Internal Medicine, East Tennessee State University, Johnson City, TN
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Student/Resident Case Report Poster - Procedures
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
INTRODUCTION: Tracheal invasion is an uncommon complication of thyroid cancer and can cause respiratory failure. We describe a case of an elderly female who presented with respiratory distress requiring intubation. Computerized Tomography chest (CT) showed large thyroid mass with subglottic extension. Bronchoscopy showed the subglottic mass was nearly totally obstructing the tracheal lumen. The mass was removed with electro cautery snare and Argo Plasma Coagulation (APC).The patient was extubated the next day without any complications.
CASE PRESENTATION: A 77-year-old Caucasian female with chronic obstructive pulmonary disease and recently diagnosed thyroid mass presented to the hospital with acute shortness of breath. Patient had multiple admissions with similar symptoms, vitals were stable except tachypnea. Physical examination was normal except upper airway wheezing. Arterial Blood gas showed acute respiratory acidosis. Patient continued to have respiratory difficulty requiring intubation. She was started on breathing treatments and steroids. Spirometry done at bedside was normal. CT (Figure 1) from a previous admission showed a large thyroid mass with subglottic extension. Flexible Bronchoscopy was done to evaluate the airways. The Bronchoscope was inserted with slowly retracting the endotracheal tube. A large mass was visualized in the subglottic region (Figure 2) causing near complete obstruction of the airway. The endotracheal tube was repositioned. The mass was removed with electro cautery snare and surrounding area of tumor was coagulated with APC. Patient was extubated without any complications. Pathology of the mass showed high grade neoplasia of unknown origin. Patient refused further workup for thyromegaly and tracheal mass.
DISCUSSION: Patient presenting with intraluminal tracheal mass often present with dyspnea and wheezing, which is usually mistaken for obstructive lung disease. CT is helpful in diagnosing and staging the tracheal tumor or metastasis. Bronchoscopy remains the gold standard for diagnosing and staging tracheal lesions. Finally, management is based on the type of the tumor but endoscopic de-bulking of the tumor is recommended to maintain airway for palliation purpose or while patient waits for the surgery. In our patient argon plasma coagulation and mechanical technique was use to debulk the tumor with good response, and patient was taken off intubation without any complications.
CONCLUSIONS: In central airway tumors, bronchoscopic intervention could alleviate life threatening airway obstruction and provide time for additional definitive treatments. APC is an effective and safe tool for alleviating central airway obstruction.
Reference #1: Compeau, C., Keshavjee, S. (1996). Management of Tracheal Neoplasms. The Oncologist, 1(6), 347-353.
Reference #2: Lee, B., Oh, I., Lee, H., et al. (2015). Usefulness of Rigid Bronchoscopic Intervention Using Argon Plasma Coagulation for Central Airway Tumors. Clinical and Experimental Otorhinolaryngology, 8(4), 396.
DISCLOSURE: The following authors have nothing to disclose: Badar Siddiqui, Disha Awasthi, Adel El Abbassi
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