Trachea

Intermittently symptomatic tracheal diverticulum: A case of a rare clinical phenomenon

September 20, 2011     Christopher L. Smelley, DO, Rebecca Bowen, MD, and Cherie-Ann O. Nathan, MD, FACS
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Abstract

Tracheal diverticula are rarely encountered, and only a handful of cases have been described in the literature. In most of these cases the patient was asymptomatic. When symptoms have occurred, they usually had an airway component such as cough, dyspnea, and recurrent respiratory infection. Imaging techniques-particularly computed tomography-are beneficial for diagnosing a tracheal diverticulum because bronchoscopy can sometimes miss the point of communication with the trachea. We report the case of a 62-year-old woman with a tracheal diverticulum that manifested as an intermittent, painful right neck mass with associated cough, dysphonia, dysphagia/odynophagia, and an occasional strangulation/choking sensation.

Subacute airway obstruction caused by a suprastomal tracheal granuloma following tracheotomy in an adult

September 20, 2011     Elizabeth A. Kelly, MD, Arunkumar N. Badi, MD, PhD, Joel H. Blumin, MD, and David M. Poetker, MD
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Abstract

We report a case of a post-tracheotomy suprastomal granuloma in the early postoperative phase that caused subacute airway obstruction in a 28-year-old woman. The patient had undergone the tracheotomy during the surgical treatment of a submental abscess. During recovery, several capping trials had failed. Therefore, direct laryngoscopy was performed on postoperative day 11, and it revealed that the airway was being obstructed by a tracheal granuloma. The granuloma was managed with a partial resection and corticosteroids. The patient was successfully decannulated with no recurrence of the granuloma. To the best of our knowledge, airway obstruction secondary to a tracheal granuloma has not been previously reported as an early complication of a traditional surgical tracheotomy in an adult. In this report, we discuss the presenting features of this case and we propose several possible etiologies.

Tracheoinnominate fistula: Successful management with endovascular stenting

July 13, 2011     Peter M. Shepard, MD, Jeffrey M. Phillips, MD, Girma Tefera, MD, and Gregory K. Hartig, MD
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Abstract

Tracheoinnominate fistula is a rare complication of tracheostomy that is associated with high rates of morbidity and mortality. Recently, endovascular stents have been described as a viable treatment option for the management of this condition. We report a case of tracheoinnominate fistula in a 40-year-old man that was successfully managed with endovascular stent placement. Our evaluation included bronchoscopy, arteriography, and computed tomographic angiography. Intraoperative localization of the fistula required selective catheterization of the innominate artery.

Aspiration of radiolucent dentures in facial trauma: Case report

December 17, 2010     Jon B. Chadwell, MD, Joshua R. Mitchell, MD, Michael Donnino, MD, Charles Peterson, MD, Paul Guentert, MD, Cliff Arnold, BA, and Mark Walsh, MD
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Abstract

Foreign body aspiration is a serious problem that may lead to complications or even death. People who sustain major maxillofacial trauma can often damage their teeth or oral prostheses, and aspiration can occur. Detection of this type of aspiration can be difficult, especially in elderly people wearing dental appliances, since many dental prostheses are not radiopaque and the aspiration is not always recognized at the time of injury. We report a specific case of extensive maxillofacial trauma from a self-inflicted gunshot wound leading to aspiration of large, radiolucent denture fragments, delayed diagnosis, and complications. The possibility of denture fragment aspiration must always be part of the differential diagnosis in an elderly trauma patient presenting with dyspnea, hypoxia or, eventually, pneumonia. This is especially so when radiologic evaluation does not reveal a foreign body, since much dental prosthesis material is radiolucent. Delayed complications of radiolucent dental prosthesis aspiration could be avoided by the inclusion of some radiopaque material within the acrylic material of the prosthesis.

Presence of biofilm on adult tracheostomy tubes

September 30, 2010     Danny Meslemani, MD, Kathleen Yaremchuk, MD, and Michael Rontal, MD
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Abstract

We conducted a prospective observational study of tracheostomy tubes with three primary goals: (1) to identify the presence and location of bacterial biofilms on adult tubes, (2) to determine how soon after insertion of a tube the presence of a biofilm could be identified, and (3) to identify the bacterial organisms that formed the biofilms on these tubes. Our study materials consisted of 7 adult tracheostomy tubes that had been changed during a routine outpatient clinic visit or hospital consultation. The tubes were examined for the presence of biofilms on the posterior aspect of the outer cannula; also, specimens were obtained from the posterosuperior aspect of the cuff on the 3 tubes that had a cuff. Samples of 2 to 3 mm were taken from each site and analyzed by scanning electron microscopy. Bacterial biofilms were found on 4 of the 7 tubes; they were present on the outer cannula of 3 cuffless tubes that had been inserted 14 days, 4 months, and 2 years previously and on the cuff of 1 tube that had been inserted 10 days previously. The biofilms were composed of gram-positive cocci in pairs that were likely consistent with Staphylococcus epidermidis.

Safety of percutaneous dilational tracheostomy in coagulopathic patients

July 31, 2010     Vinciya Pandian, MSN, CRNP, Ravi S. Vaswani, BS, Marek A. Mirski, MD, PhD, Elliott Haut, MD, Shivam Gupta, MBBS, MPH, and Nasir I. Bhatti, MD
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Abstract

Coagulopathy is one of the relative contraindications to percutaneous dilational tracheostomy (PDT). We conducted a retrospective analysis of the records of 483 patients who had undergone PDT at Johns Hopkins Hospital from January 2000 through December 2007 to investigate the safety of PDT in those who were coagulopathic. The number of patients classified as coagulopathic varied greatly according to the particular diagnostic criteria used; 164 patients (33.95%) met one of the three diagnostic criteria (an abnormality in either prothrombin time, partial thromboplastin time, or platelet count), and 32 patients (6.63%) met two or three of these criteria. Complications occurred in 16 patients (3.31%), none of whom met two or more diagnostic criteria; bleeding accounted for 5 of these complications (1.04%). No statistically significant difference was seen in complication rates between the coagulopathic patients and the controls (noncoagulopathic patients). We conclude that in the hands of an experienced surgeon, PDT can be safely performed in patients with abnormal coagulation factors provided that the surgical team strictly adheres to a standardized protocol.

Acute tracheitis

June 30, 2010     James A. Heilman, BA, Swapna K. Chandran, MD, and Robert T. Sataloff, MD, DMA, FACS
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Primary malignant melanoma of the trachea: Case report

June 30, 2010     Engin Çekin, MD, Hakan Cincik, MD, Ismail Yilmaz, MD, and Atila Gungor, MD
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Abstract

A 22-year-old man was admitted with complaints of dyspnea and hoarseness. Laryngoscopy and computed tomography of the neck revealed a 1.5 x 2-cm solid mass obstructing the trachea. The black, pedunculated mass was completely removed through a tracheal incision, and a paratracheal lymph node dissection was performed. Histopathologic examination revealed nodular-type mucosal malignant melanoma. Cranial and thoracic computed tomography, abdominal ultrasonography, and histopathologic examination of the paratracheal lymph nodes showed no metastases. No recurrence has been noted in more than 3 years of follow-up.

Pediatric tracheotomy in special populations: Comparison of operative times and survival

May 31, 2010     Catherine A. Craig, MD, Ashley Brooke Robey, MD, and Debora W. Goebel, MD
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Abstract

We conducted a retrospective study to analyze various aspects of tracheotomy in children with abnormal laryngotracheal anatomy, a congenital cardiac anomaly, both, or neither. Our study population consisted of 53 children who had undergone tracheotomy performed by a single otolaryngologist; 12 patients had abnormal laryngotracheal anatomy and 9 had a cardiac anomaly. Mean operative times were significantly longer in both of these groups than they were in children with normal anatomy (69 vs. 50 min; p < 0.0001) and in children with no cardiac anomaly (65 vs. 53 min; p < 0.05). Post-tracheotomy survival at 1 and 2 years for children with a cardiac anomaly was significantly worse than survival for those without (44 vs. 91%; p < 0.001). Likewise, children who had been intubated for 10 days or more had significantly worse survival than did those who were intubated for less than 10 days (55 vs. 95%; p < 0.001). Finally, we found that the patients with prolonged intubation, respiratory failure, and a cardiac surgical history had higher mortality rates associated with tracheotomy.

Adenoid cystic carcinoma of the trachea metastatic to the nasal cavity: A case report

December 1, 2009     Azita S. Khorsandi, MD, James E. Silberzweig, MD, Bruce M. Wenig, MD, Mark L. Urken, MD, and Roy A. Holliday, MD
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Abstract

Cases of carcinoma metastatic to the nasal cavity are rare. We report the case of a 63-year-old woman with a metastasis to the nasal cavity from a primary tracheal adenoid cystic carcinoma (ACC). The nasal tumor was treated with surgical resection. No evidence of any local recurrence was observed at 4 years of follow-up. To the best of our knowledge, no case of a tracheal ACC metastatic to the nasal cavity has been previously reported in the literature. Although rare, metastatic disease to the nasal cavity should be considered in patients who have a known primary carcinoma elsewhere and who present with nasal symptoms.

Tracheal amyloidosis-an unusual cause of stridor

April 30, 2009     Emer E. Lang, FRCS(ORL), Eimear Phelan, AFRCSI, and Helena Rowley, FRCS(ORL)
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Abstract

Amyloidosis confined to the trachea is an exceedingly rare entity. We describe the case of a 63-year-old man who presented with a history of dysphonia and stridor. Rigid bronchoscopy revealed a segment of abnormal tissue at the midtracheal level, resembling granulation tissue. A stent was placed in an attempt to secure the patient's airway, which was >50% narrowed. Although the patient's stridor disappeared completely, 5 days postoperatively it recurred, worsening within hours. Emergency bronchoscopy revealed that the tracheal stent was almost completely obstructed with amyloid and granulation tissue, despite high-dose steroid therapy, and had to be removed. Tracheostomy was performed to bypass the diseased trachea. We also highlight some of the problems encountered with tracheal stenting in benign tracheal disease.

Idiopathic tracheal stenosis

March 31, 2009     Swapna K. Chandran, MD and Robert T. Sataloff, MD, DMA, FACS
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