Trachea

Adult presentation of laryngeal cleft: Utility of the modified barium swallow study in diagnosis and management

December 19, 2014     Genevieve Houdet-Cote, MHSc; Simon R. McVaugh-Smock, MHSc
article

We present a case of laryngeal cleft in a 41-year-old man to illustrate the co-occurrence of laryngeal cleft and tracheoesophageal fistula. We advocate the use of the modified barium swallow study in the diagnosis of laryngeal cleft. We also review the advantages and limitations of the various diagnostic methods, as well as the potential for known tracheoesophageal fistula to mask laryngeal cleft. Finally, we discuss the importance of early identification of laryngeal cleft in the context of its potentially serious health implications.

An unusual presentation of anterior subglottic stenosis

June 8, 2014     Harry V. Wright, MD; Kenneth C. Fletcher, MD
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Acquired subglottic stenosis should be suspected in any patient with unexplained dyspnea weeks to months following decannulation.

Traumatic tracheostomy and spent bullet aspiration after a gunshot injury: A case report

August 21, 2013     Jack Barasa, MD; Peter M. Nthumba, MD; and Peter Bird, FRACS
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Abstract

Penetrating tracheal injuries are rare. Even rarer is the finding of intrabronchial foreign bodies caused by penetrating objects. We report a patient who experienced a gunshot injury to the trachea and mandible. The tracheal wound was debrided and used as a tracheostomy; a spent bullet in the bronchial tree was missed on initial evaluation but later successfully retrieved bronchoscopically. Spent bullet aspiration is a very rare occurrence. A careful examination of radiographs is essential to aid with the diagnosis. Flexible bronchoscopy is the best means of bullet retrieval. Management of any associated injuries is made easier after the airway is secured.

Transnasal esophagoscopy and the diagnosis of a mediastinal foregut duplication cyst

August 21, 2013     Amarbir S. Gill, BS and Jennifer L. Long, MD, PhD
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Foregut duplication cysts are true mucus-filled cysts lined with a thin epithelial layer, arising from either bronchogenic, esophageal, or neuroenteric precursor tissue.

Unusual pseudomyiasis with Musca domestica (housefly) larvae in a tracheostomy wound: A case report and literature review

July 21, 2013     Mohammad Shakeel, MS; Iram Khan, MD; Imteyaz Ahmad, MD; Zafar Iqbal, MS; Syed Abrar Hasan, MS
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Abstract

We report a case of pseudomyiasis (accidental myiasis) in a 52-year-old man who had previously undergone surgery and placement of a tracheostomy tube for laryngeal cancer. The patient presented to our outpatient department with a foul-smelling, blood-stained discharge and frequent and severe episodic pain at the site of the tracheostomy. He also reported the discharge of many whitish larvae from the site. On clinical examination, 3 of these larvae were removed from the tracheostomy wound and later identified as Musca domestica (housefly) larvae. The patient underwent further mechanical removal twice daily for 3 days, during which time 23 more larvae, or maggots, were removed. His condition improved, and he returned for regular follow-up with no recurrence or complications. Myiasis is an infestation of humans and vertebrate animals by insect larvae that feed on both dead and living tissue. Myiasis is most common in hot and humid climates in tropical and subtropical regions, such as the underdeveloped areas of India, Africa, and Southeast Asia, which provide favorable breeding grounds for flies. Myiasis is classified as specific, semispecific, or accidental, depending on whether the fly larvae require a host in order to develop. We review the literature on myiasis and its entomologic aspects in general. We also discuss the need for the proper care of tracheostomy wound myiasis because the site of such an infestation is close to vital organs in the neck. To the best of our knowledge, only 3 cases of tracheostomy wound myiasis have been previously reported in the English-language literature; 2 of them involved infestation with Chrysomyia bezziana larvae and 1 with Lucilia caesar larvae. We believe our case is the first case of tracheostomy wound pseudomyiasis attributable to M domestica larvae.

Laryngotracheal rhinosporidiosis

July 21, 2013     J. Madana, MS; Deeke Yolmo, MS; S. Gopalakrishnan, MS; Sunil K. Saxena, MS
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Abstract

Rhinosporidiosis is a chronic granulomatous disease caused by Rhinosporidium seeberi. It usually affects mucous membranes of the nose, nasopharynx, and ocular conjunctiva. Cutaneous, laryngeal, tracheal, genital, and bony dissemination is rare. Laryngotracheal involvement poses many diagnostic and therapeutic challenges. A 45-year-old South Indian man presented with complaints of a mass in both nostrils for 2 years, associated with progressive hoarseness of voice and difficulty in breathing for 6 months. Rhinosporidial lesions were seen bilaterally in the nasal cavity. Telescopic and fiberoptic laryngoscopic examinations showed reddish, strawberry-like masses with whitish spots on their surface involving the larynx and trachea. Computed tomography of the head and neck revealed soft-tissue mass lesions involving the bilateral nasal cavities and nasopharynx, extending to the oropharynx and involving the larynx and trachea. A preliminary tracheostomy was performed, followed by direct laryngoscopic excision of the laryngeal lesions and rigid-bronchoscopy-guided excision of the tracheal lesions. The patient was prescribed dapsone and advised to take it for 2 years. At 2 years of follow-up, there was no recurrence.

Supraglottoplasty for airway obstruction

June 11, 2013     Nausheen Jamal, MD; Farhad Chowdhury, DO; Reena Gupta, MD; and Robert T. Sataloff, MD, DMA, FACS
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Supraglottoplasty may be helpful in a patient with tracheotomy-dependent  adult obstructive sleep apnea/hypopnea syndrome that is causally related to or aggravated by supraglottic obstruction.

Subfreezing versus room-temperature balloon dilation of benign tracheal stenosis: A pilot study in rabbits

April 17, 2013     Benjamin J. Wycherly, MD; Matthew K. Steehler, MD; Hosai Hesham, MD; Kevin Burke, MD; Sonya Malekzadeh, MD
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Abstract

We conducted an experiment to compare collagen deposition in tracheal stenoses dilated with room-temperature balloons and stenoses dilated with balloons at a subfreezing temperature (-10°C). Six New Zealand white rabbits underwent endoscopic tracheal injury. Tracheal dilation was performed at 3 weeks postinjury with either a room-temperature balloon or a vascular cryoplasty balloon. Five surviving rabbits were sacrificed at either 2 weeks (n = 3) or 4 weeks (n = 2) postdilation (1 rabbit that was not able to tolerate dilation was euthanized during the procedure). A blinded pathologist graded histologic sections of the injured tracheas for collagen content. The tracheal collagen deposits in the 3 animals sacrificed at 2 weeks postdilation were all graded as moderate. However, at the 4-week postdilation examination, there was a marked difference in collagen deposition between the rabbit that underwent room-temperature dilation and the rabbit that underwent subfreezing dilation; while the former showed moderate collagen deposition, the deposition in the latter was only mild. In conclusion, this pilot study showed that tracheal dilation with balloon cryotherapy decreased collagen deposition in the injured airway of 1 animal. Larger studies are required to determine whether balloon cryotherapy improves the long-term patency of immature tracheal stenosis.

Tracheal carcinoid presenting as refractory cervicalgia in a postpartum patient: Correlation versus epiphenomenon

September 7, 2012     Arturo Loaiza-Bonilla, MD; Flavia Rossi, MD; Bassel Alkhalil, MD
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Abstract

Primary tracheal carcinoid tumor is an extremely rare disorder that has been reported only occasionally in the medical literature. We report a case of a 36-year-old African American woman who presented to the emergency department complaining of persistent neck pain for the preceding week. She was 2 weeks postpartum and had no significant medical history. Laboratory workup was unremarkable. Computed tomography and magnetic resonance imaging showed a polypoid mass in the trachea. After bronchoscopy and laser ablation of the mass were performed, the final diagnosis of carcinoid tumor was made. To our knowledge this is the first reported case of this tumor in a postpartum patient. Further studies regarding the interactions between the natural history of carcinoid tumors and pregnancy are warranted. Their infrequency, clinical features, and pathophysiology make tracheal carcinoid tumors a formidable and interesting diagnostic challenge.

Giant tracheocele with multiple congenital anomalies

April 30, 2012     J. Madana, MS, DNB; Deeke Yolmo, MS; Sunil Kumar Saxena, MS; S. Gopalakrishnan, MS
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Abstract

Tracheocele-an outpouching of tracheal mucous membrane-is an uncommon entity. It can occur as a congenital or acquired form. The congenital entity remains mostly dormant until adulthood, and then it typically presents as a herniation with multiple air-filled sacs. The acquired form develops as the result of blunt trauma, recurrent pulmonary infection, intubation, instrumentation, or surgery, and it typically presents as a single paratracheal cavity. We present an extremely rare case of a tracheocele associated with multiple congenital anomalies involving the face, limbs, and heart.

Outcomes of intubation in difficult airways due to head and neck pathology

March 1, 2012     Tim A. Iseli, MBBS, FRACS, Claire E. Iseli, MBBS, MS, J. Blake Golden, MD, Virginia L. Jones, MD, Arthur M. Boudreaux, MD, James R. Boyce, MD, David M. Weeks, MD, and William R. Carroll, MD, FACS
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Abstract

The purpose of this study was to examine the impact of surgical pathology, anesthesiologist experience, and airway technique on surgically relevant outcomes in patients identified by preoperative laryngoscopy to have a difficult airway due to head and neck pathology. We prospectively recorded a series of 152 difficult airway cases due to head and neck pathology out of 2,145 direct laryngoscopies undertaken between November 2005 and June 2008. One of two senior anesthesiologists specializing in head and neck procedures intubated 101 (66.4%) of the 152 patients and did so 3.3 minutes faster (p = 0.51), with better oxygenation (87.3 vs. 81.8%; p = 0.02) and fewer airway plan changes (p = 0.001) than did other, nonspecialist anesthesiologists. Predictors of failure of the first intubation plan included: cancer diagnosis (p = 0.02), previous radiotherapy (p = 0.03), and supraglottic lesions (p = 0.03). Glottic/subglottic lesions required the most intubation attempts (p = 0.02). Awake fiberoptic intubation was the most common method used (44.7%) but resulted in a change in the airway plan in 6 cases (8.8%). Gas induction maintained the best oxygenation (p = 0.01). Awake tracheostomy was infrequent (1.3%) and took the longest (p = 0.006). We concluded that difficult airways due to head and neck pathology require teamwork and a backup plan. An anesthesiologist specializing in head and neck procedures may help to avoid adverse outcomes associated with cancer, especially previously irradiated supraglottic/glottic lesions, leading to a less frequent need for awake tracheostomy.

Dilated esophagus and tracheal compression secondary to a slipped Nissen fundoplication: A case report

January 25, 2012     Roy Rajan, MD and Jerome W. Thompson, MD
article

Abstract

We describe the case of a 20-month-old girl with a gastrostomy tube who presented with stridor, daily emesis, stertor, and mild neck retractions. Endoscopic and radiologic investigations revealed a dilated esophagus, an associated tracheal compression, and a paraesophageal hernia secondary to a slipped Nissen fundoplication. The patient underwent a revision fundoplication, and her stridor, stertor, and neck retractions subsided significantly. She tolerated tube feeding without emesis and was discharged home. We recommend a careful evaluation of fundoplication in patients who have undergone the procedure who present with stridor and frequent emesis. Esophageal dilation and associated tracheal compression should be considered in the differential diagnosis, and in such a case, revision of the gastric wrap should alleviate the problem.

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