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We report a case of localized bronchial lactoferrin amyloidosis. A 47-year-old man presented with a complaint of persistent dry cough for two months. Chest computed-tomography revealed a calcification shadow of the right main bronchus; hence, a biopsy was performed, showing layered spheroid-type eosinophilic deposits in the bronchial wall. These deposits were positive for Congo red staining, exhibiting apple-green birefringence under polarized light. In addition, an electron microscopic examination demonstrated that this layered structure was formed by very thin cord-like amyloid deposits. By proteomics analysis using liquid chromatography-tandem mass spectrometry and immunohistochemistry, we confirmed that the deposited amyloid was composed of lactoferrin. While lactoferrin is known to be a precursor protein of localized corneal and seminal vesicle amyloidosis, localized lactoferrin amyloidosis of the bronchus has not been reported in the English literature. Our pathological findings suggested that localized lactoferrin amyloidosis may be caused by long-term tissue damage, and the characteristic spheroid-type appearance is thought to be associated with unique, thin cord-like amyloid deposits.

Introduction Isolated tracheobronchial injury after blunt trauma of the chest is rare. Because of the high elasticity of the chest in children, they occur mainly in the pediatric population. Case Report We report a case of a 7-year-old girl who experienced complete avulsion of the right main bronchus at the level of the carina after a horse-riding accident. The patient presented with extensive emphysema of the upper chest, neck, and face and severe respiratory distress. Endotracheal intubation led to tension pneumothorax. After insertion of two 17-mm thoracostomy tubes, pneumothorax and a massive air leak persisted. Isolated central bronchial injury was confirmed by computed tomography of the chest. Bronchoscopically guided selective intubation of the left main stem bronchus failed and the patient desaturated, requiring immediate salvage right posterolateral thoracotomy. Simultaneous occlusion of the defect, stabilization, and subsequent selective left lung intubation was possible only after placing a suture at the tracheal rim of the defect for retraction allowing compression of the defect and keeping the lumen open at the same time. Conclusion A cluster of clinical signs with subcutaneous emphysema and refractory pneumothorax with air leak of the thoracotomy tube is indicative of bronchial injury. Endotracheal intubation should be postponed in these cases until after thoracostomy tube placement, if possible. Placing a retraction suture during repair is a maneuver that helps to occlude the defect and keep the remaining tracheobronchial lumen open at the same time to establish crucial ventilation of the contralateral lung.

A person presented with multiple gunshot injury. Chest x-ray & CT whole body trauma protocol was done which showed multiples pellets of bullet in abdomen and one bullet in elbow according to entry wound. There was an entry wound without any bullet in left maxillofacial region however there was no exit wound. A bullet was noticed in tracheobronchial tree. There was no pneumothorax any signs of chest trauma or any pneumomediastinum. It is assumed that the bullet first hit the left cheek (maxilla) and lost its momentum. As the patient lost consciousness and had a fall leading to inhalation (aspiration) of bullet in the airway. As per ballistic experts it was basically a jacketed metallic bullet. As bullet moved in airway, the outer metallic core reached the trachea near carina and the soft metallic core slipped more distally to right main bronchus and bronchus intermedius. While inspection the outer metallic capsule was seen in trachea just above carina which was hollow and was gently removed with the help of foreign body forceps. The core was removed with dormia basket without any mucosal tear. The favorable outcome can be attributed as patient had no lung contusion or chest trauma and bullet was inhaled which was not very old. The evolution of bronchoscopy started with rigid one but the fibreoptic bronchoscopy (FOB) has revolutionized the pulmonary interventions. The FOB can be used with minimal traumas under local anesthesia resulting in markedly reduced morbidity and mortality.

AIM To evaluate the cardiovascular, tracheobronchial and pulmonary abnormalities associated with tetralogy of Fallot with absent pulmonary valve syndrome (TOF-APVS) on multidetector computed tomograpgy (MDCT) angiography. MATERIALS AND METHODS We conducted a retrospective review of our electronic database from January, 2014 to December, 2020 to identify pediatric patients diagnosed with TOF-APVS on MDCT angiography. Pulmonary anatomy, associated tracheobronchial and coronary compression, compression of intrapulmonary bronchi, lung parenchymal changes and other associated cardiovascular abnormalities were evaluated. RESULTS Forty-seven patients with TOF-APVS were included in the study. Compression of the airways was observed at multiple levels; 4 (8.5%) patients had carinal compression while right main bronchus and left main bronchus compression was seen in 12 (25.5%) and 16 (34.0%) patients, respectively. Forty-three (91.5%) patients showed abnormal pulmonary arterial branching at the segmental level and compression at the level of intrapulmonary bronchi was seen in 24 (51.1%) patients. Some degree of air trapping was seen in 35 (74.5%) patients whereas atelectasis was observed in 15 (31.9%) patients. Mild coronary arterial compression was seen in 3 (6.4%) patients. CONCLUSION TOF-APVS is characterized by aneurysmal dilatation of pulmonary arteries leading to a varying degree of airway compression. However, even in the absence of compression of the trachea and main bronchi, there can be distal bronchial compression secondary to abnormal pulmonary arterial branching resulting in lung abnormalities in the majority of these patients. This study highlights the importance of dedicated airway assessment in addition to cardiovascular morphological assessment by MDCT angiography, before planning surgery.

Lung carcinoid tumours are rare neoplasms with a favourable prognosis. Bronchoplasty can be a conservative treatment for typical carcinoid tumours and can be applied for patients with limited respiratory function. We report the case of a 34‐year‐old woman, with a polypoid tumour located at the distal right main bronchus. Bronchial biopsy showed a typical carcinoid tumour. After resection of the tumour in the right main bronchus, bronchoplasty was performed by end‐to‐end anastomosis of the remaining right main bronchus, right upper lobar bronchus, and the upper bronchus intermedius. Bronchoscopy showed a good quality anastomosis with slightly reduced endoluminal calibre only. The post‐operative period was uneventful and the patient was discharged at the seventh day. One year later, no complications occurred and the patient is still being followed up regularly., In this article, we try to demonstrate the possibility of creating a "neo‐spur" without lobectomy to treat an intra‐bronchial typical carcinoid tumor.

Esophageal atresia (EA) is the most frequent congenital anomaly of the esophagus. According to Gross Classification, type-C esophageal atresia is the most common type. The Atlas of Esophageal Atresia by Kluth describes multiple variations of defects in EA. We present a female baby of 36 weeks’ gestation, with IIIb13 esophageal atresia, an extremely rare subtype of type-C EA. During pre-surgical bronchoscopy, we observed the presence of a double fistula, which was confirmed in the surgery. The first fistula between trachea and esophagus, and the second fistula between right main bronchus and esophagus, both in the distal esophagus. We made an esophageal anastomosis preserving the total length of the distal esophagus. This is the first report in over 20 years, and the third in the literature. The patient had a satisfactory evolution. After five months of follow-up the patient eats by suction only, with adequate weight gain, without suggestion of stenosis or gastroesophageal reflux.

Congenital bronchopulmonary foregut anomalies are uncommon group of disorders that reflect upon the embryological development of the foregut. These conditions represent the intimate embryological proximity of the foregut and tracheobronchial tree. The radiological findings are typically of segmental or lobar consolidation with abnormal vascular supply or foregut communication. We report a case of a breathless neonate with oesophageal origin of the right main bronchus. This communication was well demonstrated with the help of an oesophagogram. The radiologist plays an important role by identifying this communication on a CT done for non-resolving lung collapse. Contrast-enhanced CT of the chest is also useful in evaluating the vascular supply of the lung that helps in diagnosis and also directs treatment.

Objective: To report the 8-year follow-up outcomes, treatment of complications, and prognosis in children with congenital tracheal stenosis after metal airway stent implantation. Methods: Retrospective analysis was performed on the clinical records of children who had airway stents placed between May 20, 2011 and May 31, 2016, and on their follow-up records collected by November 31, 2019. Results: During the 8 years follow-up, 41 children underwent airway stenting under flexible bronchoscopy and participated in the follow-up investigation. There were 26 cases with left main bronchus (LMB) stenosis (63.4%), 16 cases with congenital tracheal stenosis (CTS, 39.0%), 12 cases with right main bronchus (RMB) stenosis (29.3%), and 1 case of subglottic stenosis (2.4%). A total of 76 stents were implanted, and 21 patients died after implantation. There were 34 children (82.9%) with congenital heart disease (CHD), while other diseases accounted for less than 5%. Among children with CHD and those with other conditions, the number of death cases was 19 and 9, respectively; no significant differences were observed between the two groups (P>0.05). The most frequent complications were increased airway secretion (75.8%), stent deformation (66.7%), and granulation tissue hyperplasia (60.6%). The airway stenosis (45.5%) and stent migration (12.1%) occurred at a moderate rate. The less common complications were airway softening (6.1%), and stent fracture (6.1%). Conclusions: The placement and removal of the metal stent are convenient and quick procedures that can relieve the symptoms of dyspnea caused by airway stenosis in the case of an emergency. After stent implantation, the primary disease should be actively treated, and the stent should be removed as soon as possible after the cause of airway stenosis is successfully removed. Larger stents are more likely to cause complications; thus, a good follow-up system should be established to timely address all the complications.

Introduction: Tracheal tear is a rare, life-threatening complication of endotracheal tube insertion. We report a case of a patient who had a tracheal tear following a routine video-assisted thoracoscopicsuergery (VATS) sympathectomy. A silicon Y-stent was inserted while she was put on extracorporeal membrane oxygenation (ECMO) as a bridge to the destined therapy. Case Report: A 24-year old lady presented with bilateral palmar hyperhidrosis since childhood. Apart from sweaty palms and feet, her physical examination was otherwise unremarkable. She subsequently underwent VATS sympathectomy where she was intubated with double lumen,32fr endotracheal tube (ETT). Bronchoscopy confirmed the correct ETT placement, and her surgery was performed without delay. However, she desaturated intraoperatively, thus the surgery was stopped. On table bronchoscopy done by the pulmonology team confirmed a deep laceration measuring 1cm above carina, and 2cm in length. Rigid bronchoscopy with Y-stent insertion was done on day 5 of event, in view of persistent laceration. The Y-stent was deployed successfully with intended limb 2cm in the right main bronchus (RMB) and 1cm in the left main bronchus (LMB). The patient was able to be weaned off ECMO 1-day after Y-stent insertion, and she was subsequently well to be discharged. She successfully had her Y-stent removed 2-months post procedure and a surveillance bronchoscopy 1-month post Y-stent removal showed well healed tracheal tear site with presence of granulation tissue. Conclusion: Y-stent insertion in a patient with small tracheal injury is a viable and feasible option. Its deployment had improved the healing process of the injury site.

Objective To determine the frequency of various foreign bodies (FBs) retrieved from the airway during bronchoscopy in children at the National Institute of Child Health (NICH), Karachi, Pakistan. Study design Cross-sectional descriptive study. Place and duration Department of Pediatrics Surgery, NICH, Karachi, Pakistan from June 1, 2017 to November 30, 2017. Methodology Patients referred from the ER and Pediatrics Medicine Department, NICH, Karachi with a suspicion of tracheobronchial foreign body aspiration (FBA) was included in the study. Results A total of 96 children were studied. There were 71 males (74%) and 25 females (26%). Eighty-seven (90.6%) were below five years and nine (9.4%) were more than five years of age. Mean time interval between FBA and presentation at hospital was 15 h. FB was located primarily in the right main bronchus (54%), followed by left bronchus (40%) and trachea (6%). Betel nut was the most common FB retrieved in 87.5%. Other FBs were whistle 3.1%, peanut 3.1%, seed 1%, and miscellaneous 5.2%. Conclusions FBA is more common in male children, mostly below five years of age. During bronchoscopy, it was found that the FB was mostly located in the right main bronchus. Betel nut was found to be the most common FB aspirated.

Background/aim Thoracic neurogenic tumors are most frequently located in the posterior part of the mediastinum or on the chest wall, along the intercostal nerves. Schwannomas are very well tolerated for a long period, until the tumor reaches a large size and compression of the neighbouring mediastinal organs, chest wall or spine appears. The purpose of this article was to present a case of a giant right forth intercostal nerve Schwannoma, completely resected by a right antero-lateral thoracotomy. In addition, intrathoracic giant neurogenic tumors are a rarity. Case report The patient presented with only diminished tolerance to physical activity with no other obvious symptoms. Standard chest radiography revealed a well-defined opacity of subcostal intensity, occupying two thirds of the right hemithorax, forming a common body with the mediastinal shadow. Thoracic computed tomography (CT) identified a 21/11 cm solid mass that compresses the right lung and the right main bronchus with both a solid component and a central liquid area. Open surgery was performed in order to remove the tumor, which was 20.5/12.5/9 cm in size and weighed 1,830 g, well defined, with no invasion of the adjacent organs, having a solid-fibromatous aspect as well as a central necrotic area. The origin of the tumor was confirmed from the posterolateral part of the forth intercostal nerve. Pathology examination and immunohistochemistry confirmed the diagnosis of a benign Schwannoma. Conclusion Benign intrathoracic Schwannomas are asymptomatic for long periods and the main therapeutic option is complete surgical resection. The surgical approach, either open or video-assisted is dictated by the localisation of the tumor, local extension and most importantly the size of the neurogenic mass.

Background Post-esophagectomy bronchopleural fistulas can be life-threatening in patients who are exhausted, for example, by surgical stress and pleural infection; therefore, establishment of a reliable surgical procedure is extremely important. We here report a novel procedure entailing muscle flap closure for bronchopleural fistula. Case presentation A 64-year-old man developed a right bronchopleural fistula after esophagectomy. Because he was exhausted by surgical stress and malnourished, we considered reliable surgical closure of the fistula essential. Intraoperatively, it was found to connect with the membranous portion of the right main bronchus. We decided to close the fistula with a pedicled fourth and fifth intercostal muscle flap. After separating the intercostal muscles near the angle of the rib, we passed a muscle flap between the azygos vein and bronchus and sutured it securely to the fistula. The postoperative course was uneventful, and there was no thoracic infection. Postoperative bronchoscopy confirmed the muscle flap had securely closed the fistula. Conclusions The route and suturing technique of the intercostal muscle flap to a fistula are important, especially in exhausted patients.

In recent years, high flow nasal cannula is being increasingly used. Most studies showed positive results when used in hypoxaemic respiratory failure. Its use in a patient with a large endobronchial mass has not yet being described. We report a patient who presented with hemoptysis and hypoxaemic respiratory failure second to a large mass obstructing the right main bronchus. High flow oxygen via nasal cannula was initiated with a quick improvement of the hemoptysis and the oxygen saturation. Thus, allowing the patient to be rapidly stabilized.

We present a 67‐year‐old man with allergic bronchopulmonary aspergillosis (ABPA), whose chest computed tomography (CT) scans showed localized circumferential bronchial wall thickening in the right main bronchus to middle truncus. Chest CT scans showed high‐attenuation mucus in the right B8 bronchus. Bronchoscopy showed narrowing of the right main bronchus and inspissated mucus plugging in the right B8 bronchus. Histological examination of the right main bronchus revealed bronchial inflammation with numerous neutrophils and plasma cells. Treatment with corticosteroid and antifungal agents resulted in resolution of the symptoms and right bronchial lesions. The clinical course may indicate that the bronchial lesions were associated with ABPA., The typical bronchial manifestations of allergic bronchopulmonary aspergillosis (ABPA) include intraluminal retention of inspissated mucus plugging and chronic inflammation of airway walls with eosinophils, lymphocytes, and neutrophils. Bronchiectasis and bronchial wall thickening can be seen on chest computed tomography (CT) scans. However, localized circumferential narrowing of the bronchus has not been reported. Herein, we report such a patient with ABPA, whose bronchial lesions disappeared after treatment with prednisolone and antifungal agents.

Background Coccidioidomycosis is an endemic disease in the Americas. No cases have been reported in Africa. Patient A 23-year-old HIV seronegative Ugandan man was referred to Mulago National Referral Hospital in Kampala, Uganda with a 10-month history of haemoptysis and difficulty breathing, and a 6-month history of localized swellings on the extremities. He had associated weight loss and drenching sweats, but no fevers. He had taken anti-tuberculosis medicine for 2 months with no improvement. He had never travelled out of Uganda. On physical examination, he had cystic swellings and ulcerated lesions on the extremities. He had tachypnoea, crackles in the chest and mild hepatomegaly. Bronchoscopic examination showed two masses occluding the right main bronchus. Bronchoscopic biopsy showed findings consistent with coccidioidomycosis. The patient improved with antifungal treatment and was discharged. Conclusion We report the first case of disseminated coccidioidomycosis with pulmonary and cutaneous manifestations in Africa. LEARNING POINTS Coccidioidomycosis is an endemic disease in the Americas and may now be present in Africa. The patient had taken anti-tuberculosis medicine for 2 months with no improvement. Coccidioidomycosis should be considered in the differential diagnosis of tuberculosis.

Background Bronchial fistula is a severe complication of pneumonectomy with a high mortality rate. We previously reported a technique for bronchial closure to prevent bronchial fistula in a canine model. We described that mucosal ablation could result in primary wound healing and involve mucosal tight adhesions histologically. In this paper, the pathologic findings of one patient, who underwent autopsy 4 years after surgery, were reviewed. Case presentation A 70-year-old Japanese man was diagnosed with malignant pleural mesothelioma and underwent right extra-pleural pneumonectomy. The right main bronchus was cut using a scalpel. When closing the bronchial stump, the bronchial mucosa was ablated by electric cautery and sutured manually using 3-0 absorbable sutures. The bronchial fistula was not found after pneumonectomy. Four years after surgery, the patient died of recurrent malignant pleural mesothelioma and underwent autopsy. Macroscopic evaluation showed tight adhesions and white scars on the bronchial stump. Microscopic findings showed few inflammatory cells and α-smooth muscle actin (α-SMA)-positive cells. Conclusions The results from this case suggested that bronchial mucosal ablation leads to robust agglutination of bronchial stump over years. This technique is not only simple but also reliable to prevent bronchial fistula.

This study aimed to report cases of high-lying azygos arch and discuss the embryological basis of its development by a thorough evaluation of the anatomical features assessed using computed tomography (CT) images. This study was approved by our institutional review board. We retrospectively reviewed chest CT images between November 2011 and November 2018. To determine high-lying azygos arch, we set the upper margin of the T4 vertebral body as the reference level. Regarding the embryological development of high-lying azygos arch, we retrospectively reviewed the CT images of 105 patients with tracheal bronchus to identify the location of the azygos arch. We noted that on three cases CT images, the azygos arch was located higher than the upper margin of the right main bronchus, and drained into the proximal superior vena cava (SVC) at a level higher than the conventional T4 or T5 vertebral level. All 105 patients with right tracheal bronchus showed azygos arch above the tracheal bronchus. This variation in the location of the azygos arch can mimic pathological lesion on plain radiographs, and, therefore, it is important to be aware of high-lying azygos arch. Our findings show that the azygos arch may have possibly migrated downward during embryological development.

Three-dimensionally printed organ models that facilitate preoperative simulations have the potential to improve outcomes of surgical procedures. Here, we report a case involving a 54-year-old man diagnosed with lung cancer of the right upper bronchus that was invading the right main bronchus. A right upper lobectomy with carinoplasty was performed. Although complete excision of the tumor was achieved, exertional dyspnea redeveloped 4 months post-surgery. Chest computed tomography revealed that airway stenosis caused by granulation had deformed the airway. Ablation of the granulation and airway stenting was required to improve the patient’s symptoms. Prior to performing airway stenting, a three-dimensionally printed airway model was constructed, and the Y-shaped silicone stent used was modified in accordance with the model. After stenting, both the right and left bronchi were preserved, and the patient’s symptoms improved. The three-dimensional printed airway model enhanced the accuracy and safety of the airway stenting procedure performed.

Background Although there are lots of variations of pulmonary veins including dangerous type that could cause serious complications during surgery, limited information has been reported about these variations. We have experienced an extremely rare anomaly of the right superior pulmonary vein during right superior lobectomy. We used a technique called “non fissure” to manage the right superior pulmonary vein, and the results were satisfactory. Case presentation A 66-year-old woman with lung nodules visited our hospital. Chest computed tomography revealed multiple ground glass nodules in the right lung, the main pulmonary nodule was 11 mm in diameter and presented mixed density. The patient had a previous history of rectal cancer surgery. Contrast-enhanced three-dimensional computed tomography showed that the right superior pulmonary vein abnormally ran between the pulmonary artery trunk and the right main bronchus. We performed a right superior lobectomy and lymph node sampling by uniportal video-assisted thoracoscopic surgery. The pathological findings showed microinvasive adenocarcinoma with no lymphatic metastasis. She was discharged 7 days after surgery without any surgical complications. Conclusions Although the variation of pulmonary vein is uncommon, it is dangerous to misidentify in the operation. Preoperative three-dimensional computed tomography is useful for avoiding unexpected bleeding. The technique “no fissure” might be a useful way to manage the variation of pulmonary vein.

Malignant pulmonary granular cell tumor (GCT) is extremely rare and difficult to distinguish from benign GCT. Most GCTs are neural-type and express S-100. However, a small subset of tumors sub-classified as the non-neural type do not express S-100. We report a case of malignant non-neural-type GCT in the lungs.A 77-year-old woman felt chest discomfort and dyspnea in July 2019. She had never smoked and had no medical history other than hypertension and diabetes mellitus.She was initially evaluated at a local hospital. Flexible bronchoscopy showed total occlusion of the right main bronchus by a mass-like lesion. Biopsy of the mass lesion revealed chronic inflammation. The patient visited for re-evaluation in September 2019. Rigid bronchoscopy showed worsening of the total obstruction of the right main bronchus by a tumor mass, such that the carina was not visible. Additionally, endobronchial nodules were observed on the medial side of left main bronchus. The tumor masses of both main bronchi were removed by bronchoscopic intervention, but the right main bronchus was not opened. Biopsy revealed malignant GCT, favoring the non-neuronal type (S-100-negative).We report an extremely rare case of malignant pulmonary GCT negative for S-100 in immunohistochemistry. In this case, surgical resection was not possible because the tumor was diagnosed at a fairly advanced stage and had spread to involve the contralateral main bronchus. The patient chose to be treated at another hospital and was thereafter lost to follow-up. Keywords: Malignant pulmonary granular cell tumor, S-100-Negative, Non-neural type

We present the case of a 56-year-old male diagnosed with achalasia ten years previously without follow-up. He presented with fever, dysphonia and dyspnea associated with a constitutional syndrome of one month of evolution. Laboratory tests showed leucocytosis of 15,870/ul. The chest radiography confirmed mediastinal widening and a chest computed tomography (CT) showed full esophageal dilation up to 10 cm compressing the trachea and right main bronchus, with tapering at the esophagogastric junction.

The right lung is the larger of the two lungs and is divided in three lobes: the upper, middle and lower lobes. The major fissure separates the upper and middle lobes from the lower lobe and the minor fissure separates the upper lobe from the middle one; the latest is usually less evident. The right lung is fixed centrally by the hilum that is composed by the right main bronchus, the pulmonary artery and the superior and inferior pulmonary veins, and distally by the inferior pulmonary ligament. From the hilum the right main bronchus, the pulmonary artery and the superior and inferior pulmonary veins divide into lobar, segmental and subsegmental branches. The lymphatic drainage pathway from subpleural lymphatic vessels runs with the arteries and bronchi and subsequently into the segmental, lobar, interlobar, hilar and mediastinal nodes.

A 31-year-old woman presented with progressive breathlessness since 1 year. Flexible bronchoscopy revealed a vascular tumor completely occluding the right main bronchus. A diagnosis of primary endobronchial myxoma was made. Tumor debulking was performed using rigid bronchoscopy. This enabled right lower lobectomy. A literature search yielded 12 cases of primary pulmonary myxoma, and only 2 previous reports of endobronchial myxoma. Most tumors were incidentally detected and were cured surgically. Endobronchial myxomas are rare and are usually asymptomatic. Treatment involves surgical excision. Rigid bronchoscopy serves as a bridge to surgery and can reduce the extent of surgery.

A fifty seven year old male patient was admitted to our clinic because of complaints of cough and sputum. Computed tomography revealed by a 36x25 mm mass on the lateral of the 7th left rib, a 50x52 mm mass on the right main bronchus, growing 40x34 mm lymph nodes on the carina and paratracheal, 60x42 mm mass on the right adrenal and extensive bone metastasis. Squamous cell carcinoma was diagnosed by performed bronchoscopic biopsy. Scalp dermal biopsy was taken upon detection of extensive lesions on the skin.Scalp biopsy was reported squamous cell carcinoma infiltration.The last time when was given radiotherapy to footwell metastasis, the patient was fever and hypotension, we were accepted intensive care unit. In this article, we aimed to discuss rarely aggressive skin metastasis in a squamous cell carcinoma, a type of lung cancerin the light of current literature data.

Inflammatory myofibroblastic tumor (IMT) is a rare neoplasm exhibiting local aggressive behavior and needs to be differentiated from sarcoma and sarcomatoid carcinoma in particular. Its exact etiology is uncertain. IMT is more common among children and young adults. Pulmonary, gastrointestinal, genitourinary, retroperitoneal sites are frequently affected. History, physical examination, laboratory workup and imaging modalities have limited diagnostic value. IMT has a tendency for local recurrence. Here, we report a case of an IMT of the bladder in a female patient with difficulty urinating, dysuria and pelvic pain.

Background Tracheobronchial injury is one of the least common injuries in the scenario of blunt chest trauma. However, around 81% of patients with airway injury die immediately or before arriving at the emergency department due to tension pneumothorax. It presents with non-specific signs and symptoms challenging prompt diagnosis. Case presentation A 15-year-old adolescent who was riding a bicycle suffered an accident when he fell down a cliff, approximately 5 m deep. Upon admission to the emergency department, he presented with signs of respiratory distress. The airway was secured and a thoracoabdominal angiography was performed. The image reported pneumomediastinum, a small right pneumothorax, areas of pulmonary contusion, and an image of loss of continuity in the anterior superior wall of the right main bronchus highly suggestive of bronchial rupture. The bronchial lesion was then confirmed by fiberoptic bronchoscopy. Taking into account the patient’s characteristics, conservative management was chosen, and the patient was transferred to the intensive care unit (ICU) where protective tracheal intubation was performed. Conclusions A delay in diagnosis increases the rate of complications, mainly infectious complications and the formation of granulation tissue that could potentially obstruct the airway, impacting the patient’s outcome. The first step in the management of these patients is securing the airway, which should be done immediately. The gold standard for the diagnosis and characterization of airway injuries is bronchoscopy as it is the most effective tool to assess topography, extent, and depth of the lesion.

BACKGROUND Tracheobronchial foreign body (TFB) aspiration is a significant cause of respiratory problems in children. The timely diagnosis of TFB is important to decrease the mortality rate and the incidence of complications. Advances in radiology have led multi-slice spiral computed tomography (MSCT) to become the best technique for diagnosing TFB. METHODS We performed a retrospective study over 5 years from July 2008 to June 2013. We collected information on children who were diagnosed with a TFB by bronchoscopy, and analyzed age, sex, location, type of foreign body, and various MSCT manifestations. RESULTS A total of 382 children were included and 68.6% of them were aged 1 to

Introduction: To assess the predictors of hemoptysis using second-generation cryoballoon (CB). Methods: Thirty patients with hemoptysis after second-generation CB ablation and 60 age-, gender-, and body mass index-matched controls were recruited. Anatomic parameters were obtained from preprocedural cardiac computed tomography (CT). Pulmonary vein isolation was performed with 28-mm balloon using single 3-minute freeze technique. Results: Clinical and procedural characteristics were similar between the groups. A shorter distance between left superior PV (LSPV) and left main bronchus (LMB) was associated with hemoptysis (7.8 +/- 4.3mmvs. 12.5 +/- 3.5 mm, P l 0.001), whereas no significant difference in the distance between right superior PV (RSPV) and right main bronchus (RMB) was found between groups (11.9 +/- 3.5 mm vs. 12.9 +/- 4.6 mm, P = 0.089). Additionally, the mean thickness of the connective tissue interposed between RSPV and RMB was significantly thicker than that between LSPV and LMB in both groups (both P l 0.001). A stepwise logistic multivariate analysis identified only the LMB-LSPV distance as an independent predictor of hemoptysis (odd ratio [OR] 2.676; 95% CI 1.121-4.843, P l 0.001). A cutoff value l= 9.5 mm predicted hemoptysis after CB ablation with 93.8% sensitivity and 75.0% specificity. Conclusion: Hemoptysis is a relatively rare event following second-generation CB ablation. The bronchi location obtained from CT aids in identifying high-risk population for the complication.

We report the case of a 16-year-old male patient who was involved in a traffic accident and transferred to the emergency department with mild chest pain. We initially did not find evidence of tracheal injury on computed tomography (CT). Within an hour after presentation, the patient developed severe dyspnea and newly developed subcutaneous emphysema and pneumoperitoneum were discovered. Abdominal CT showed no intra-abdominal injury. However, destruction of the right main bronchus was identified on coronal images of the initially performed CT scan. Emergency exploratory surgery was performed. The amputated right main bronchus was identified. End-to-end tracheobronchial anastomosis was performed, and the patient recovered without any complications.

Tracheal tumors are rare and difficult to diagnose. Moreover, delays in diagnosis are very common because the symptoms are nonspecific. As a result, tracheal tumors are commonly mistreated as chronic obstructive pulmonary disease or bronchial asthma. We report a case of a 49-year-old male who presented with a 3-month history of dyspnea and cough. Chest computed tomography scan showed a 1.5×1.3 cm homogenous tumor originating from the right lateral wall of the tracheobronchial angle into the tracheal lumen as well as a 0.5×0.4 cm round nodular lesion at the right upper lobe with multiple mediastinal lymph nodes enlargement. Bronchoscopic findings revealed a broad-based, polypoid lesion nearly obstructing the airway of the right main bronchus. The patient was diagnosed with pleomorphic adenoma which is the most common benign tumor of the salivary glands, but rarely appears in the trachea. Upon surgery, tracheal pleomorphic adenoma and co-existing active pulmonary tuberculoma that had been mistreated as bronchial asthma over 3 months was revealed. Following surgery, the patient underwent anti-tuberculosis treatment. No recurrence has been detected in the 3 years since treatment and the patient is now asymptomatic.

Inflammatory myofibroblastic tumours (IMTs) are rare and clinically benign in childhood, and malignant in adults. The aetiology of IMTs is not clear, and recent studies report it as true neoplasm rather than a reactive or inflammatory lesion. IMTs can involve any part of the body, but are usually common in lungs. These are rarely seen in adults and tracheal involvement is also rare in both adults and children. We describe an 18-year-old woman who presented with respiratory difficulty to the emergency department. On clinical examination, the patient had complete absence of breath sounds on the right side of the chest. CT of the chest and virtual bronchoscopy revealed a polypoidal soft tissue mass lesion involving the carina with occlusion of right main bronchus. Endoscopic-assisted resection was performed under general anaesthesia and the final pathological diagnosis was tracheal IMT.Resezione transtracheale endoscopio-assistita di un raro tumore miofibroblastico infiammatorio della trachea di un paziente adulto: case report.I tumori miofibroblastici infiammatori sono rari in età pediatrica, età nella quale sono clinicamente benigni; sono invece maligni in età adulta. L’eziologia non è chiara, recenti studi affermano che essi siano delle vere neoplasie piuttosto che delle lesioni reattive o infiammatorie. I tumori miofibroblastici infiammatori sono raramente riscontrati negli adulti e il coinvolgimento tracheale è raro sia nei bambini sia negli adulti. Noi descriviamo il caso di una paziente di sesso femminile di diciotto anni, che si è presentata al pronto soccorso per difficoltà respiratoria. All’esame clinico della paziente si evidenziava assenza dei suoni polmonari a destra, pertanto si eseguiva TC del torace e la broncoscopia virtuale rivelava una lesione polipoide soffice che coinvolgeva la carena occludendo completamente il bronco principale di destra. La resezione endoscopio-assistita è stata eseguita in anestesia generale e all’esame istopatologico definitivo la diagnosi è stata di tumore miofibroblastico infiammatorio.

Introduction. Asymptomatic Bochdalek hernia in adults is a rarity. The aim of this paper is to present a rare case of Bochdalek hernia among adults and to point out to significance of clinical suspicion and important role of imaging techniques in reaching the exact diagnosis of this abnormality. Case report. A patient, aged 68 years, came to the Clinic of Pulmonology complaining of constant dyspnea, coughing and fatigue. Computed tomography (CT) findings were dominated by the large rear right diaphragmatic hernia with the hernial sac that reached the carina trachea and urged the principal bronchi. The stomach, duodenum and proximal part of jejunal winds, as well as a greater amount of omental and mesenteric adipose tissue were localized in hernial sac. Radiography of gastroduodenum showed: entry of the esophagus into the cardia was in the level of the right main bronchus. Stomach was mainly located in the chest (cardia, upper corpus half - to the level of the right main bronchus). Operation was indicated. First, we made right thoracotomy and the hernia sac was separated from the right lung and then we performed median laparotomy and the contents of the hernia sac were returned to the abdominal cavity; diaphragm defect was reconstructed with prolen mesh. Conclusion. We presented a rare case of right sided Bochdalek hernia which was discovered at late age and surgically treated with success.

Introduction: Pediatric tracheobronchial foreign body aspiration can be a life-threatening emergency, especially in young children because of their decreased respiratory reserve and smaller-diameter airways. Case presentation: We herein present a case in which a 1-year-old female child aspirated a 9-cm long metal chain into the lower trachea and right main bronchus. The chain was removed via low tracheotomy and rigid bronchoscopy under general anesthesia. An intravenous anesthetic alone with a muscle relaxant was used to ensure an immobile airway during surgery instead of the more commonly used inhalation anesthetics with spontaneous ventilation. Conclusion: The case re-affirms that the removal of some large and irregular airway foreign bodies is a challenging procedure that requires a proper anesthetic plan and coordination with surgeons. Key words: Foreign bodies; General anesthesia; Pediatric

A 9-year-old girl with Glenn circulation suffered from massive atelectasis of the left lung caused by bleeding during cardiac catheterization. The atelectasis resulted in frequent hypoxia leading to oxygen saturation (SpO2) of 40%-50%. In the intensive care unit, we performed a unilateral lung recruitment maneuver (ULRM) for 2 days. The ULRM involved placement of a bronchial blocker in the right main bronchus and application of continuous positive airway pressure to the left lung without hemodynamic deterioration. Eventually, SpO2 improved to 80%-85%. ULRM can be a treatment option for unilateral atelectasis in a child with Glenn circulation.

Tracheobronchial injuries (TBIs) have a high mortality rate unless aggressive treatment is used. The clinical presentation is variable depending on the presence of associated injuries and on whether the peribronchial tissues remain intact. High index of clinical suspicion and accurate interpretation of radiological findings are necessary to diagnose the injury at presentation and allow prompt surgical intervention with primary repair of the airway. Herein, we describe a case of complete right main bronchus rupture in a 10-year-old boy diagnosed by chest computed tomography.

Introduction. Tracheobronchial disruption is a rare disorder, usually accompanied by a severe blunt chest trauma that quite rarely appears as an isolated event. Case Report. This is a case report of a right main bronchus disruption, due to an injury to the right hemithorax, caused by a falling tree trunk. The disruption was accompanied by mediastinal emphysema, fractures of the 4th and 5th ribs on the right side and compound sternal fracture. The patient was operated in general anesthesia, through right thoracotomy approach, followed by successful right main bronchus reconstruction by interrupted suture technique, without anatomic resection of the lung parenchyma. Conclusion. Although this injury is rare, with suspicion of bronchial rupture, bronchoscopy confirms the diagnosis and leads to better prognosis.

Rationale The main challenge facing anesthesiologists during endotracheal mass resection is securing effective airway management during surgery. It is important to select an airway intubation and airway maintenance method according to the patient's condition and the characteristics of the mass. Patient concerns A 74-year-old woman with aggravated dyspnea for 1 year was scheduled to undergo endotracheal mass excision under general anesthesia. Diagnosis The mass was 4 × 3 × 3 cm ovoid-shaped, and located 4 cm above the carina, occupying 41% of the tracheal lumen in a preoperative chest computed tomography and bronchoscopy. Interventions After preparing extracorporeal membrane oxygenation in case of the inability to ventilate and intubate, we attempted awake bronchoscopy-guided nasotracheal intubation using a reinforced endotracheal tube with an inner diameter of 5.5 mm and outer diameter of 7.8 mm after a translaryngeal block. The tube was passed around the mass without resistance and placed right above the carina. With the tube pulled back above the mass, another tube was introduced from the opened trachea below the mass to the right main bronchus. Following the resection of the tracheal portion containing the mass, the posterior wall of the remaining trachea was reconstructed. The tube placed in the right main bronchus was removed and the tube in the upper trachea was introduced right above the carina. The patient's head was kept flexed once the anastomosis of the trachea was completed, and the surgery ended uneventfully. Outcomes The mass was confirmed as schwannoma by histopathological finding. The patient was discharged from the hospital on the 6th postoperative day without complication. Lessons Awake bronchoscopy-guided intubation is a safe airway management method in patients with an endotracheal mass. Close cooperation between anesthesiologist and surgeon, and preparation for airway management before surgery is essential. It is necessary to establish alternative plans that can be implemented in the case that intubation and ventilation are not possible.

A 62-year-old male with long-standing smoking history presented with haemoptysis. Plain chest X-ray showed abnormal findings proximate to the right pulmonary hilum. Bronchoscopy revealed a fragile exophytic tumour of the right wall of the lower third of the trachea, infiltrating the right main bronchus (75% stenosis) and the right upper lobar bronchus (near total occlusion). Contrast-enhanced chest computed tomography demonstrated a 7.2 × 4.9 cm tumour contiguous to the above-mentioned structures, mediastinal lymph node pathology, and a vessel coursing inferiorly to the left of the aortic arch and anterior to the left hilum. Despite the tumour constricting the right superior vena cava (SVC), no signs of SVC syndrome were present. In this case, the patient does not present with SVC syndrome, as expected due to the constriction of the (right) SVC caused by the tumour, since head and neck veins drain through the persistent left superior vena cava (PLSVC). PLSVC is the most common thoracic venous anomaly with an incidence of 0.3% to 0.5% of the general population and it is a congenital anomaly caused by the failure of the left anterior cardinal vein to regress and to consequently form the ligament of Marshall during foetal development. It is associated with absence of the left brachiocephalic vein and in 10% to 20% of cases the right SVC is absent. Two potential draining points of the PLSVC have been previously reported. In the majority of cases PLSVC drains directly into the coronary sinus, but less frequently it drains into the left atrium or the left superior pulmonary vein (LSPV). In cases where the PLSVC drains into the coronary sinus, congenital heart defects are rare. The patient usually remains asymptomatic and PLSVC is an incidental finding during radiographic imaging or medical procedures. When the PLSVC drains into the left atrium or the LSPV, a right-to-left shunt is formed; a condition usually asymptomatic. In some reported cases this PLSVC variant presents with persistent, unexplained hypoxia or cyanosis and embolisation causing recurrent transient ischaemic attacks and/or cerebral abscesses. This PLSVC variant is more often associated with absence of the right SVC and congenital heart abnormalities.

Tracheobronchial disruption is one of the most severe injuries caused by blunt chest trauma. It may cause airway obstruction and resulting life-threatening respiratory deficiency. However, the clinical presentations are variable and frequently difficult to diagnose. We report a case of a previously healthy 16-year-old man with complete right main bronchial transection sustained after a vehicular accident, who had progressive dyspnea, subcutaneous emphysema in the neck and anterior chest wall, and bilateral tension pneumothorax. Prompt chest tube drainage for suspected bilateral tension pneumothorax and a tracheal intubation were performed. Shortly after the positive pressure ventilation, severe subcutaneous emphysema developed and he was at risk for developing shock. Additional chest tubes were inserted. An emergency bronchoscopy showed rupture of the right main bronchus. After changing to a double lumen endotracheal tube, the patient's condition improved. A surgical closure was performed and postoperative bronchoscopy showed good repair. The patient was discharged without complications.

Pulmonary agenesis is a very rare congenital anomaly characterized by the absence of pulmonary parenchyma and its vasculature. The diagnosis is usually during childhood. Herein, we report a case of incidental discover right pulmonary agenesis in adulthood male. A 30-year-old male presented with pre-operative medical evaluation for varicocele. There was no complaining from respiratory symptoms. He underwent plain chest X-ray and post-contrast CT scanning was performed using 64 multi-detector CT scanner. Chest Plain X-ray revealed cardiac and mediastinal shift to right side with hyper-inflated left lung crosses to right side. Multi-detector computed tomography examination revealed total absence of right lung with compensatory hyperinflation and increase volume of left lung. Hyper-inflated left lung extended to right hemithorax. Mediastinal structures including heart and great vessels were displaced to middle and lower parts of right hemithorax. Descending aorta located to anterior to thoracic vertebrae. Right pulmonary artery was absent. Right main bronchus was rudimentary. No detected other organ anomalies. No detected bony thoracic cage abnormalities.

Introduction Airway complications following lung transplantation are associated with significant morbidity and mortality; they can result to significant functional impairment, poor quality of life and frequent hospitalizations. Anastomotic stenosis remains the commonest post-transplant airway complication with an estimated incidence between 1.6-32%. Non-anastomotic bronchial stenosis is rare and is not reported frequently. Case Report We present the case of a 46-year-old female cystic fibrosis patient requiring right lower bilobectomy following bilateral sequential lung transplant in April 2018, which was complicated by stricture of the right main bronchus requiring serial dilatations. Recurrent chest infections related to chronic Achromobacter xylosoxidans lead to complete right middle and lower lobe consolidation and collapse, with a ventilation/perfusion scan demonstrating almost complete absence of lobar ventilation and perfusion. Subsequent fibrotic narrowing of the bronchus intermedius resulted in bi-lobar failure and right lower bilobectomy in June 2020. Stenting of the bronchus intermedius was not considered feasible because the stenosis was in close proximity to the right upper lobar orifice. Thus, lung resection was undertaken utilizing a 2-port video assisted thoracoscopic technique. Intra-operatively the lung was found to be densely adhered to the chest wall and the diaphragm. Division of adhesions and lung mobilisation was challenging and utilization of various surgical techniques to avoid lacerations and prolonged leakage. Careful dissecting of the atrial cuff anastomosis was done to preserve the upper lobe venous supply. The pulmonary artery branches were dissected through their regular anatomical locations by accessing the oblique fissure. The middle and lower lobe bronchi were divided en bloc within their respective fissures to limit disruption of the vasculature of the bronchial stumps and prevent post-operative fistulae. Summary Treatment of stenotic anastomosis after lung transplantation can be challenging. Our case demonstrates that surgical management may be indicated when more conservative techniques have failed. Limits for surgery in lung failure need constant revisit; our experience shows that management in highly specialized centres improves overall outcomes.

Endobronchial tuberculosis (EBTB) is the most frequent complication of primary pulmonary tuberculosis (PTB) in children. The aim of the study was to analyze characteristics and clinical role of bronchoscopy in diagnosis of childhood EBTB. A retrospective, descriptive study was undertaken in 157 children with EBTB undergone flexible bronchoscopy (FB) between January 2006 and June 2014. The median age of the enrolled patients was 3.4 years, with 73.2% of patients under five years old. The most common subtype was tumorous type (145/157, 92.4%). If only involved bronchus were considered, the common affected sites were right middle lobe bronchus (49/228, 21.5%), left upper lobe bronchus (41/228, 18.0%), right upper lobe bronchus (41/228, 18.0%), right main bronchus (35/228, 15.4%), respectively. Children younger than five years old were at higher risk to have multiple endobronchial lesions (P=0.044), with an odds ratio of 2.313 (95% confidence interval: 1.009–5.299). Before the bronchoscopy, only 16 (10.2%) patients were highly suspected of EBTB, while the others were diagnosed as PTB without EBTB (69.4%), or misdiagnosed as pneumonia or foreign body aspiration (20.4%) on admission. The patients under five years old are at high risk to progress to EBTB and have multiple endobronchial lesions. The most frequent subtype of EBTB in children is tumorous type. The lesions are seen in the right bronchial system more frequently. FB should be performed to detect the endobronchial lesions in suspected patients as soon as possible.

A 73-year-old man was referred to our hospital after a 2-week history of bloody sputum and cough. Computed tomography (CT) images of the chest showed a mass grouped with mediastinal lymph nodes, and bronchoscopy showed a projecting mass in the right main bronchus. After a transbronchial biopsy, the patient was diagnosed with squamous cell carcinoma (T4N2M0 stage IIIB). The patient was treated with systemic chemotherapy, consisting of cisplatin (40 mg/m2, days 1 and 8) and docetaxel (30 mg/m2, days 1 and 8), and concurrent thoracic irradiation at a daily dose of 2 Gy. On day 35 of treatment, the patient complained of a sore throat and cough. A CT of the chest showed punctate low-attenuation foci between the esophagus and bronchus. Gastrointestinal endoscopy and bronchoscopy demonstrated a fistula in the middle intrathoracic esophagus and the left main bronchus. The patient’s symptoms gradually improved, and the fistula was closed after the suspension of chemoradiotherapy. Radiotherapy was resumed and completed on day 82. However, on day 108, he developed a fever and cough, and a tumor with fistula was revealed in the right main bronchus. He had an esophageal stent inserted, but he later died of sudden hemoptysis.

Background: Tracheal intubation in oro-maxillofacial surgery is an important issue during operation. Objective: The purpose of the present study was to demonstrate the feasibility and the reliability of submandibular tracheal intubation as an alternative method for airway management in oro-maxillofacial surgery. Methodology: This clinical trial was conducted in the Department of oromaxillofacial Surgery at Dhaka Dental College and Hospital, Dhaka from January 2010 to June 2011 for a period of one and half year. Patients suffering from painful fractures associated with displaced nasal fracture were selected as study population. Results: A total number of 9 patients were recruited for this study of which 1 was female and 8 were males and the age range was between 16 to 51 years. The technique was found easy and offers a secure airway to the anaesthetist, an optimal operating field and an opportunity to check the dental occlusion with limited morbidity for the patient. In all patients the submandibular tracheal tube was extubated after the operation without complications or difficulties. Accidental dislodgement of the tube to the right main bronchus occurred in one patient while carrying out the procedure. It was rapidly detected and corrected. No other complications were encountered. Conclusion: Submandibular tracheal intubation is a safe, simple and effective technique for upper airway management when both oral and nasal tracheal intubations are not convenient in some oromaxillofacial surgery. Journal of National Institute of Neurosciences Bangladesh, 2015;1(2): 41-46

Tracheobronchial damage is very rare in clinical practice and represents no more than 1% of all injuries caused by blunt trauma. Nearly 80% of patients die before reaching the hospital. Most ruptures are observed in the right main bronchus and are located within 2 cm of the carina trachea. The highest mortality rate applies to patients with bilateral bronchial injuries. Nonspecific symptoms, additionally masked by complaints regarding other damaged organs, delay the diagnosis and surgical treatment. The aim of this article is to present one particular clinical case and to discuss it in conjunction with a literature review.

Reinforced endotracheal tubes (ETTs) are designed to resist kinking or compression. However, these have a potential risk of being obstructed or severed by a patient’s bite. We report a case in which a reinforced ETT was severed by tube-bite while the patient was in the prone position during an intensive care unit stay. Bronchoscopic evaluation showed that the severed distal part of the tube had lodged in the patient’s right main bronchus, and it had to be surgically removed. The patency of reinforced ETTs should be carefully monitored in patients intubated in the prone position.

Context: Bronchial fibroepithelial polyp is a very rare benign endobronchial tumor. Typically, it is a slow growing lesion, and the differential diagnosis includes other benign and malignant endobronchial tumors. Case Report: We report a case of a 75-year-old female who complained of intermittent productive cough. Computed tomography of the thorax showed a solid nodule with lobulated contours in the right main bronchus and subtotal atelectasis of the right lower lobe. Bronchoscopy with biopsy confirmed the diagnosis of a bronchial fibroepithelial polyp. Conclusion: This case is illustrative and demonstrates the importance of imaging methods and of histopathological correlation for the accurate diagnosis of this benign treatable lesion.