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Congenital anomalies of the right main bronchi have not been fully described. Bronchial anomalies are usually asymptomatic unless they coexist with other abnormalities. We describe a rare bronchial anomaly in a 2-month-old girl in which the right upper lobe, middle lobe, and lower lobe bronchi all originated at the same point as a result of a developmental teratogenic long right main bronchus and an absent bronchus intermedius. Furthermore, the left main bronchus contained a proximal segment of stenosis. This combination of anomalies, along with right upper lobe atelectasis and left-sided hyperinflation, resulted in a severe right mediastinal shift and respiratory distress. The mediastinum was returned to midline with endoscopic placement of an in-dwelling tracheobronchial stent into the left main bronchus. To the best of our knowledge, the specific developmental anomaly in our patient has not been previously described.

Tracheobronchopathia osteochondroplastica (TO) is a well documented benign entity of endoscopic interest. We describe a case of 76-year-old patient who presented with fever, cough, purulent sputum during the past four days, and presence of an ovoid shadow in right upper zone of his chest X-ray. Medical history included diagnosis of colon diverticuli identified by colonoscopy 3 months ago. Chest CT revealed a compact elongated lesion containing air-bronchogram stripes. Bronchoscopy showed normal upper airways and trachea but presence of unequal sized mucosal nodules, protruding into the lumen, along the entire length of the right main bronchial mucosa. No other abnormal findings were detected. Moreover, brushing and washing smears from the apical segment of right upper lobe (RUL), where the compact lesion was located, were negative for malignancy. Biopsy from the mucosal nodules of right main bronchus showed presence of cartilaginous tissue in continuity through thin pedicles with submucosal cartilage. This finding posed the diagnosis of TO while RUL lesion was cleared by antibiotic treatment. Case is reported because, to our knowledge, it represents a unique anatomic location of TO which was confined exclusively in the right main bronchus mucosa without affecting trachea.

We present 2 cases of a large thymoma with invasion to the hilum of the lung and pleural dissemination. Case 1: a 47-year-old woman was diagnosed with a type B3 thymoma with abundant left pleural effusion and multiple pleural masses, Masaoka stage IVa. A radical resection was planned after chemical pleurodesis and systemic chemotherapy. The left main pulmonary artery and left upper and inferior veins were dissected and resected in the pericardium, while the left main bronchus was cut behind the pericardium through a median sternotomy. Next, the median incision was closed and a left posterolateral thoracotomy was made, thus allowing the pleuropneumonectomy to be safely performed. Case 2: a 47-year-old woman was diagnosed with a type B3 thymoma with lymph node swelling and multiple pleural masses, indicating Masaoka stage IVb. Following induction chemotherapy, a thymothymectomy combined with a right pleuropneumonectomy was performed under a median sternotomy followed by a right posterolateral thoracotomy. The left brachiocephalic vein (BCV) was reconstructed with a ringed polytetrafluoroethylene (PTFE) graft, followed by resection of the right BCV. Next, the right main pulmonary artery and right upper and inferior veins were resected in the pericardium, and the right main bronchus was cut behind the pericardium, followed by reconstruction of the right BCV. Finally, the median incision was closed and a right posterolateral thoracotomy was made, thus allowing performance of a safe pleuropneumonectomy. The median sternotomy allowed safe dissection of pulmonary vessels surrounding the hilum of the lung and, in combination with a posterolateral thoracotomy, was required for performing a pleuropneumonectomy in patients with a huge thymoma with pleural dissemination. Electronic supplementary material The online version of this article (doi:10.1186/s40792-015-0071-z) contains supplementary material, which is available to authorized users.

A 15-month-old girl developed persistent cough with no associated history of foreign body aspiration. Chest X-ray showed a U-shaped radiopaque foreign body, which was initially thought to be a hairpin, in the right main bronchus. Rigid bronchoscopy was performed and the foreign body turned out to be a light-emitting diode (LED) bulb. In this article, we report our experience of LED bulb aspiration in children, with the view to raise the awareness of clinicians about this potentially life-threatening emergency.

Measure the displacements of endotracheal tube (ETT) tip displacement during head and neck movements.Observational study.Ear-nose-throat (ENT) and neurosurgery operating room.We performed a maximal head-neck movement trial on 50 adult patients, American Society of Anaesthesiologists 1 or 2. Patients with body mass index35 kg · m(-2), height150 cm, airway malformations, pulmonary diseases, difficulties in neck flexion or extension, previous ENT surgery or radiotherapy, gastroesophageal reflux, or dental instability were excluded from the study.ENT and neurosurgery.We measured the change in distance between the ETT tip and the carina, using a fiberscope through the ETT.After intubation, a wide disparity of tube tip distance to the carina in the neutral position was noted with a median of 5.0 (3.5-7.0) cm. Cephalad tube movement was documented following maximal head and neck extension in 34 (68%) patients and right head rotation in 25 patients (50%). Caudal tube displacement was due to maximal head and neck flexion in 38 patients (76%) and left head rotation in 25 patients (50%). Selective right main bronchus intubation was noted in 2 (4%) patients after maximal head extension.Maximal head and neck movements led to unpredictable tube displacements. Proper reassessment of tube positioning after head and neck movement of intubated patients is therefore mandatory.

A 41-year-old woman with a background of asthma was preparing for a party on New Year9s Eve when she developed a mild wheeze. Concerned her symptoms would develop and impact on festivities, she located her uncapped salbutamol inhaler in her handbag. Ignoring the coarse rattle as she shook it, she proceeded to take a deep inspiration. Instantly, she felt a painful scratch in her pharynx followed by a harsh cough, which persisted over the next few minutes and became associated with haemoptysis. She was taken to the accident and emergency department. Chest X-ray revealed a radiodense foreign body in the distal right main bronchus. During endoscopy, an earring, causing subtotal occlusion in the right lower lobe bronchus was found and extracted. Her observations remained within normal limits throughout. The importance of replacing caps on inhalers when not in use is illustrated and should be encouraged when inhaler technique is taught or reviewed.

A 25-year-old female patient presented with dry coughs of 20 days duration and fever for four days. Examination of respiratory system revealed no significant abnormality. Chest radiograph was normal. CT scan of the thorax revealed endobronchial opacity in the right main bronchus suggestive of a foreign body. Patient retrospectively recollected history of betel nut aspiration just prior to onset of symptoms. Flexible bronchoscopy revealed a large sized blackishbrownish large foreign body (betel nut) in the right main bronchus which was successfully removed using the flexible bronchoscope itself. Due to the hygroscopic character of betel nut, it had absorbed moisture and had considerably increased in size. Although rigid bronchoscope is the preferable modality for removal of large sized airway foreign bodies, flexible bronchoscope is especially useful and often preferable as it obviates the need for general anesthesia. On examination, blood pressure (100/78mmHg), pulse rate (94/ min) and respiratory rate (22/min) were normal. Examination of chest revealed no significant abnormality. Other systemic examination was also unremarkable. Posteroanterior radiograph of chest was normal (Figure 1). In view of persistent symptoms, CT scan examination of the thorax was (Figure 2) done. It revealed endobronchial opacity in the right main bronchus suggestive of a foreign body which was almost completely occluding the lumen of the right main bronchus. Hyperlucency of the right lung fields was also observed suggestive of post obstructive hyperinflation. The opacity looked well defined and did not appear to arise from the wall of the bronchus. Patient’s history was reviewed again and she recollected that on the night prior to onset of symptom, she was chewing a betel nut and while laughing on a joke during conversation she had likely aspirated it. With a diagnosis of FB aspiration in the right main bronchus, Background

Communicating bronchopulmonary foregut malformation (CBPFM) type IA is extremely rare and is associated with a high mortality rate. This malformation manifests with communication between the lung and the foregut, and this can lead to esophageal atresia and tracheoesophageal fistula (EA-TEF) to the distal pouch. To detail radiographic findings of CBPFM type IA cases and to summarize an appropriate therapeutic strategy for the management of this disorder. Medical data for two patients with CBPFM type IA were retrospectively reviewed with regard to radiographic characteristics, therapy, and outcome. Both cases were initially misdiagnosed due to the presence of EA-TEF. Unusual atelectasis of the lateral lung was observed in chest radiographs, while non-aerated hypoplastic right lung and agenesis of the right main bronchus were detected by computed tomography. A final diagnosis was made by esophagogram. Only one patient survived following surgery. CBPFM type IA is a rare condition and is extremely difficult to diagnose. However, CBPFM type IA should be suspected in patients manifesting EA and atelectasis of a unilateral lung on a chest radiograph. The decision to perform a pneumonectomy or bronchoplasty depends on the degree of exiting permitted due to pulmonary damage assessed by computed tomography.

Tracheobronchial foreign body aspiration is a serious condition that might result in mortality and it necessitates emergency intervention. Studies in literature report cases of pin aspiration related to headscarf use in Muslim countries. The most frequent symptom in foreign body aspirations is coughing. Radio-opaque foreign bodies can be detected through lung radiology. Following diagnosis, the foreign body needs to be removed as soon as possible. The removal procedure is carried out by flexible fiberoptic bronchoscopy or rigid bronchoscope. We hereby present the case of a patient who presented to the emergency department with headscarf pin aspiration and whose radiography results revealed 2 pins in the abdomen and one pin in the right main bronchus., Trakeobronşiyal yabancı cisim aspirasyonu mortaliteye neden olabilen ve acil müdahale gerektiren ciddi bir durumdur. Literatürlerde Müslüman ülkelerde başörtüsü kullanımı ile ilgili iğne aspirasyon vakaları raporlanmıştır. Yabancı cisim aspirasyonunun en sık belirtisi öksürüktür. Radyo-opak ise yabancı cisim akciğer radyolojisi ile tespit edilebilir. Tanı konar konmaz, yabancı cisimin kısa sürede çıkarılması gerekir. Çıkarma işlemi fleksibl fiberoptik bronkoskop veya rijit bronkoskop tarafından yapılmaktadır. Burada, başörtüsü iğnesi aspirasyonu neticesinde acil servise başvuran ve radyografi sonuçlarında karında 2 ve sağ ana bronşta 1 adet tespit edilen bir olgu sunuyoruz

WOS:000376564000045, Ana bronş rüptürü ile sonuçlanan künt göğüs travmaları oldukça nadirdir ve muhtemelen yüksek bir hastane öncesi mortaliteye sahiptir.. Bu yaralanmalar, solunum zorluğu ve eşlik eden yaralanmalardan dolayı yüksek oranda mortaliteye sahiptir. Altı yaşında erkek çocuğu, künt toraks travmasından dolayı kliniğimize kabul edildi. Başka bir merkezde sağ pnömotoraks nedeniyle tüp torakostomi uygulanan hasta yetersiz akciğer ekspansiyonu nedeniyle kliniğimize refere edilmiş. Fizik muayenede orta düzeyde interkostal retraksiyon, taşipne ve siyanoz mevcuttu. Geliş anındaki direkt akciğer grafisinde sağda total pnömotoraks vardı ve hilus inferiora yer değiştirmişti. Hastaya rijid bronkoskopi yapıldı ve sağ ana bronşta total rüptür görüldü. Hastaya sleeve üst lobektomi yapıldı. Bronş rüptürlerinde erken tanı ve tedavinin önemini vurgulamayı amaçladık., Blunt chest trauma resulting in rupture of a main bronchus is rare and prob- ably have a high prehospital mortality.These injuries are ofen fatal because of respiratory distress and the high frequency of associated multiple organ injuries. A six-year-old boy was admitted our clinic due to blunt chest trauma. The tube thoracostomy was performed for the right pneumothorax at another surgical cen- ter. He was referred to our clinic due to inadequate expansion of the lung. On the physical examination, there was middle intercostal retraction, cyanosis and tachypnoea. The initial chest x-ray showed total pnemothorax on the right side and the hilum replaced by inferiorly. The rigid bronchoscopy was performed and the the rupture of main bronchus was seen. The sleeve upper lobectomy was per- formed. We aimed to emphasize the important of early diagnosis and treatment in the bronchial ruptures.

Lung cancer combined with severe airway stenosis is a medical emergency, and unlike mild-to-moderate stenosis, is difficult to treat with percutaneous or bronchoscopic biopsy and stenting. We report the successful treatment of a case of lung cancer with severe airway stenosis that was treated sequentially with initial airway angiography, forceps biopsy using interventional radiology, stent placement, regional perfusion chemotherapy through a bronchial artery and radiotherapy. A 66 year-old male patient presented with a 1-month history of a productive cough, with dyspnea in the preceding 6 days. A chest spiral CT scan showed obstruction of the right hilum and complete right lung atelectasis with plugging of the right main bronchus. The patient was initially managed with oxygen before undergoing airway angiography and biopsy. A Y-shaped stent was placed through the affected bronchus, which alleviated the atelectasis. The patient further responded to locally-delivered chemotherapy and regional radiotherapy. After two years of follow-up, the patient was still alive, and no longer breathing difficultied, chest CT review showed that the tumor was no significant progress. Sequential therapy with a range of interventions can lead to an improved quality of life and a prolonged survival duration in a patient with an acute presentation of severe airway stenosis.

Foreign body aspiration is a possible complication of dental treatment that may result in a life-threatening situation. The foreign body is often spontaneously ejected from the airway, but in other cases, surgical intervention is needed. Prevention, diagnostic procedures, treatment and complications are discussed.Three cases of aspiration of dental instruments are described: the piece was localised in the right main bronchus in two cases and in the left main bronchus in one case.All three cases underwent surgery (resection and bronchoscopy); in one case, the surgical attempt failed, and the foreign body was not located by radiography; it was assumed to have been expelled spontaneously.The management of dental materials and instruments requires particular care, especially if the patient is supine or semi-recumbent. The dentist must be able to manage emergency situations in which patients accidentally inspire or swallow dental instruments or materials during treatment. Preventive techniques must be put in place because these incidents are preventable if the correct precautions are taken.

Bronchovascular fistula is a rare but fatal complication in lung transplant recipients. We report the successful salvage of a right pneumonectomy performed in a patient with a fistula between the right main bronchus and the pulmonary artery after ulcerative bronchitis caused by Aspergillus fumigatus.

Foreign body aspiration is common in children, especially those under 3 years of age. Chest radiography and CT are the main imaging modalities for the evaluation of these children. Management of children with suspected foreign body aspiration (SFBA) mainly depends on radiological findings. To investigate the potential use of low-dose multidetector CT (MDCT) and virtual bronchoscopy (VB) in the evaluation and management of SFBA in children. Included in the study were 37 children (17 girls, 20 boys; age 4 months to 10 years, mean 32 months) with SFBA. Chest radiographs were obtained prior to MDCT in all patients. MDCT was performed using a low-dose technique. VB images were obtained in the same session. Conventional bronchoscopy (CB) was performed within 24 h on patients in whom an obstructive abnormality had been found by MDCT and VB. Obstructive pathology was found in 16 (43.25%) of the 37 patients using MDCT and VB. In 13 of these patients, foreign bodies were detected and removed via CB. The foreign bodies were located in the right main bronchus (n = 5), in the bronchus intermedius (n = 6), in the medial segment of the middle lobe bronchus (n = 1), and in the left main bronchus (n = 1). In the remaining three patients, the diagnosis was false-positive for an obstructive pathology by MDCT and VB; the final diagnoses were secretions (n = 2) and schwannoma (n = 1), as demonstrated by CB. In 21 patients in whom no obstructive pathology was detected by MDCT and VB, CB was not performed. These patients were followed for 5–20 months without any recurrent obstructive symptomatology. Low-dose MDCT and VB are non-invasive radiological modalities that can be used easily in the investigation of SFBA in children. MDCT and VB provide the exact location of the obstructive pathology prior to CB. If obstructive pathology is depicted with MDCT and VB, CB should be performed either for confirmation of the diagnosis or for the diagnosis of an alternative cause for the obstruction. In cases where no obstructive pathology is detected by MDCT and VB, CB may not be clinically useful.

Wir berichten uber einen 50-jahrigen Patienten mit bekanntem nicht-kleinzelligem Lungentumor, bei dem im Vorfeld eine tumorbedingte, rechtsseitige Hauptbronchusstenose mittels Neodym-YAG-Laser behandelt wurde. Im Verlauf entwickelte der Patient eine Totalatelektase der rechten Lunge und eine den linken Hauptbronchus einbeziehende Stenose der distalen Trachea. Eine vollstandige Visualisierung dieser langstreckigen Stenose durch die konventionelle Bronchoskopie gelang nicht. Die Multidetektor-CT-generierte virtuelle Tracheobronchoskopie zeigte die vollstandige Ausdehnung des Befundes und ermoglichte zudem eine exakte pra-interventionelle Planung vor Stent-Implantation. Im Rahmen einer Kontrolluntersuchung liesen sich wiederum mit Hilfe der virtuellen 3D-Tracheobronchoskopie die korrekte Lage des Stents und seine Durchgangigkeit verifizieren. Unser Fallbericht beschreibt eine sinnvolle, schnell verfugbare und nicht-invasive Methode, das Tracheobronchialsystem bei Patienten mit intraluminalem Tumorwachstum adaquat darzustellen und so vor und nach Stent-Implantation zu evaluieren. We report about a male 50-year-old patient with known non-small cell lung cancer and tumor-associated stenosis of the right main bronchus already treated with Neodym-YAG-laser coagulation. Eight months later the patient was readmitted to hospital and revealed complete occlusion of the right main bronchus and subtotal stenosis of the distal trachea and the left main bronchus. Conventional tracheobronchoscopy failed to visualize the post-stenotic parts of the left main bronchus due to the length and degree of stenosis. Multidetector-CT-generated virtual tracheobronchoscopy was able to demonstrate complete intraluminal tumor extent thus making precise pre-interventional measurements for stent implantation possible. Furthermore, post-interventional re-evaluation by virtual tracheobronchoscopy confirmed correct position and patency of the stent located within the distal trachea and the left main bronchus. Our case report demonstrates a non-invasive and easy approach for evaluating the tracheobronchial system in a patient with tumor-associated airway stenosis including the possibility for viewing beyond post-stenotic segments.

The purpose of this study was to retrospectively assess the role of early postmortem CT in evaluating support-line misplacement to improve future treatment in the trauma setting.We included all postmortem CT examinations that were performed for trauma patients within the 1st hour after declaration of death in our tertiary medical center between August 1, 2008, and August 31, 2013. Correct placement of the following support lines was evaluated: endotracheal tubes (ETTs), chest drains, central venous catheters (CVCs), and nasogastric tubes (NGTs). Prehospital resuscitation efforts were started in all cases.Early postmortem CT was performed on average 22 minutes after declaration of death in 25 consecutive patients with severe trauma. Overall, 14 subjects (56%) had suboptimal or misplaced support lines. Of ETTs inserted into 18 trauma victims; three (17%) were mislaid in the right main bronchus and five (28%) were near or at the level of the carina. Of chest drains inserted into 13 subjects, 10 were suboptimally positioned (77%). Of CVCs inserted into eight subjects (seven femoral and one brachiocephalic), one femoral CVC (13%) was malpositioned in the soft tissues of the pelvis. Of NGTs inserted in five trauma victims, one was folded within the pharynx.Early postmortem CT for patients who have experienced severe poly-trauma can be of important educational value to radiologists and the trauma teams, providing immediate feedback regarding the location of the support lines and possibly contributing to improved training and command of the learning curve by medical staff.

Bronchial blockers are simple alternative methods of facilitating placement of devices for one-lung ventilation. The Coopdech bronchial blocker (Daiken Medical, Osaka, Japan) has been clinically introduced to perform one-lung ventilation with a single-lumen tracheal tube [1]. The distal tip of the Coopdech bronchial blocker has a pre-formed angulation. We experienced a case of fracture of the tip of the Coopdech bronchial blocker during insertion for one-lung ventilation. A 65-year-old female was scheduled for video-assisted thoracoscopic surgery and lung biopsy for suspected solitary pulmonary nodule in her right middle and lower lobes. Her medical history was unremarkable except for well-controlled asthma. The patient’s airway examination revealed Mallampati II and a thyromental distance of 4-finger breadths. Her chest computerized tomography revealed no abnormality of the trachea or major bronchi. Her trachea was easily intubated with a 7.5 mm internal diameter (ID) single-lumen tracheal tube (HiLo oral/nasal tracheal tube, Mallinckrodt, Athlone, Ireland). A Coopdech bronchial blocker was then inserted into the tracheal tube, and the length of the blocker was about 40 cm from the tip of the blocker to the connector of the tracheal tube. A pediatric fiberoptic bronchoscope (FI-7RBS, Pentax Medical Company, Montvale, NJ, USA) was passed through the single-lumen tracheal tube, and the tip of the blocker was visualized between the carina and the tip of tracheal tube. Despite repeated attempts under bronchoscopic guidance, the blocker could only be inserted into the left main bronchus. After removing pediatric fiberoptic bronchoscope, the tip of the bronchial blocker was rotated to the right side and then advanced blindly into the right main bronchus. After advancing the blocker for 2–3 cm, the resistance increased abruptly. Tip fracture of the bronchial blocker, which was folded backward, was visualized by reinserted pediatric fiberoptic bronchoscope. Subsequent attempts to withdraw the blocker failed because the bent tip hooked the tracheal tube. Under laryngoscopic guidance, subsequent attempts to remove both the tracheal tube and bronchial blocker also failed because the bent tip hooked the vocal cord. Both the tracheal tube and bronchial blocker were reinserted up to the carina, and the tip of the tracheal tube was positioned 2 cm above the carina, which was a relatively large space, with bronchoscopic guidance. The fractured tip of the bronchial blocker was rotated to the

Neurogenic benign tumors arising from the trachea and bronchus are relatively rare. We experienced three cases of neurofibroma of the bronchus which were successfully treated by transbronchial electrical snaring and Nd-YAG laser abrasion. The first was a 67-year-old man with right lung cancer, who was pointed out to have a neurofibroma in the left main bronchus. The second was a 34-year-old man with an obstruction in the right main bronchus due to neurofibroma. The third was a 66-year-old woman with a complete obstruction in the left main bronchus due to schwannoma. All patients were successfully treated to remove the tumors and obtain a patency of the bronchus by transbronchial electrical snaring and Nd-YAG laser abrasion. We also review 23 reported cases of endobronchial neurogenic tumors and discuss the efficacy of endoscopic treatments for endobronchial neurogenic tumors.

No abstract available. Article truncated at 150 words. The patient is a 22 year old man with long standing history of recurrent laryngeal papillomatosis since childhood. He was referred to the hospital by his ENT surgeon and pulmonology was consulted for evaluation of pneumonia and lung mass. Initial chest x-ray (Figure 1A) demonstrated a white out of the right lung. A CT scan (Figure 1B) obtained showed a pedunculated mass in the right main stem and extensive post obstructive pneumonia. At bronchoscopy, a near total occlusion of the right main stem bronchus was seen with extension in to the trachea (Figure 2). Piecemeal excision of the mass was done using multiple snare passes (Figure 3). The right main stem was subsequently cleared and the distal airway found patent with no endobronchial lesions (Figure 4). The mass continued to obstruct the right upper lobe take off completely. Pathology was consistent with squamous papilloma with dysplasia. Further work up revealed …

Bronchomediastinal fistula is an extremely rare complication resulting from diseases such as mediastinitis or mediastinal malignancies. In patients with lung cancer, bronchomediastinal fistula formation has rarely been reported, except during post-chemotherapy or post-radiation therapy complications. An 84-year-old visited our hospital to receive palliative radiation therapy for squamous cell carcinoma of the right main bronchus T4N2M1a. During an early course of radiation therapy, chest computed tomography (CT) scans revealed bronchomediastinal fistula between the right main bronchus and the enlarged sub-carinal lymph nodes. Radiation therapy was, therefore, discontinued and the patient received only supportive care.

Trakebronsiyal yaralanmalar, farkli yerlesim yerlerinde basit bir membranoz trakea yirtigindan ruptur veya kopmaya kadar degiskenlik gosterebilir. Bazen kucuk yirtiklar tansiyon pnomotoraksa neden olabilir iken, ana brons rupturleri pnomotoraks veya hemotoraksa yol acmayabilir. Trakeobronsiyal yaralanmalarin tanisi ilk olarak dikkatli oyku ve ayrintili fizik muayene ile konur. Bronsiyal yaralanma suphesi varsa, tani yontemleri hizlica kullanilmalidir. Bu yazida, 22 yasinda erkek hastada sag ana bronsun travmatik komplet kopmasi ve basarili tedavi teknigi sunuldu. Anah tar soz cuk ler: Kopma; brons; gogus travmasi; cerrahi. Tracheobronchial injuries may vary from a simple tear of membranous trachea to the rupture or avulsion in different locations. A small tear may cause tension pneumothorax sometimes, while main bronchial rupture does not lead to pneumothorax or hemothorax. The diagnosis of tracheobronchial injuries is initially based on a careful history and detailed physical examination of the patient. In case of suspected bronchial injury, diagnostic methods should be carried out rapidly. In this article, we reported a 22-year-old male case of traumatic complete avulsion of the right main bronchus and its successful management technique.

Covered self expandable metallic airway stents (SEMS) have been used for benign tracheal stenosis, post intubation tracheal stenosis, tracheal burn or trauma, tracheo-broncho-malacia, and extrinsic compression of trachea. Their placement is considered to be permanent, with open surgery the only way to remove the stent, though there are few cases reports of their removal with the bronchoscope, but the complications after their removal are very high. In our patient, one and a half years after placement of SEMS, she developed cough with dyspnoea, video bronchoscopy showed stenosis above the level of stent with granulation tissue inside the stent, stent fracture in lower part and stent migration to right main bronchus, thus she had all conceivable complications of stent placement. The stent was removed with the help of rigid bronchoscope under general anaesthesia. She was discharged the following day. The case is being reported because it was unique in having all the possible complications of stent placement, and rare as we could take out the stent in Toto. Thirdly, the stent could be removed without any complication.

An 83-year-old male presented with dyspnoea and stridor. He had undergone pneumonectomy 40 years ago. CT scan revealed gross shift of mediastinum (post-pneumonectomy syndrome) with tortuous trachea kinked at the thoracic inlet. Fibre optic bronchoscopy showed a near total expiratory closure of trachea, right main bronchus, and segmental bronchi confirming tracheobronchomalacia. He was managed with long length, low tracheostomy in view of his poor general condition of permitting more invasive procedures. He showed adequate clinical improvement and was discharged home. Tracheobronchomalacia in post-pneumonectomy syndrome requires emergent management. Its occurrence after 40 years is very rare and may be easily missed. It can be diagnosed with dynamic CT and FOB. Although invasive management with stenting or surgical methods is routinely advised, conservative care can be effective in selected cases.

Objective: Secondary confirmation of endotracheal (ET) tube position by ultrasound image. Design: Prospective, randomized study. Setting: A medical center-based tertiary pediatric intensive care unit. Patients: A total of 59 patients aged from newborn to 17 yrs old underwent ET tube insertion because of cardiopulmonary arrest or impending respiratory failure. Intervention: Ultrasound imaging was performed immediately before and after the ET tube placement procedure. The most frequently used ultrasonic scanning window was the subxiphoid window at the mid-upper abdominal, just beneath the xiphoid process and the lower margin of liver. The sector angle was set as wide as possible (90 degrees) so that the bilateral diaphragm could be well scanned. Measurements and Main Results: Using the ultrasound imaging method, we successfully identified all of two esophageal intubations and eight incidents of initial ET tube misplacement, which had been positioned down to the right main bronchus. Finally, we successfully identified all 59 of the correct placements of ET tubes in the trachea. Conclusions: Ultrasound imaging of diaphragm motion is a useful, quick, noninvasive, portable, and direct anatomic method for assessment of ET tube position. We think it should be considered the method of choice for the secondary confirmation of the ET tube position.

A 55-year-old man was admitted to the emergency department with severe dyspnea and hoarseness, starting immediately after a hypotensive syncope attack at home. Pulmonary auscultation revealed generalized stridor and right-sided wheezing, with no finding in the upper airway on direct laryngoscopy. Chest X-ray and computed thorax tomography revealed a high-density foreign body on the carina, causing partial obstruction in the right main bronchus. The fractured dental plate, probably aspirated during the syncope attack, was successfully removed by rigid bronchoscopy. The postoperative period was uneventful and the patient was discharged on the same day. Rapid physical and radiologic examination of patients with severe acute dyspnea is vital for determining the treatment modality and preventing any potential mortality.

This is a case of 2 years and 6 months girl who has been suffering from shortness of breath, vomiting and dysphagia with solid food since one month. She was diagnosed initially in a local hospital with hyperactive air way disease and given sulbutamol with minimal improvement. One day prior to presentation to our hospital she was eating (olives) then she aspirated, get chocking and developed cardiac arrest. CPR done in the local hospital and we have received her intubated. Investigations and interventional procedures including a chest X-ray showed a total collapse of the right lung due to a round foreign body occluding g right main bronchus which was removed via a bronchoscopy with round metalic foreign body consisting with a button battery in the upper esophagus which was removed by oesophoscopy with communication with trachea. This child would not have developed serious complications such esophagotracheal fistula if the foreign body had been identified and removed early on.

Objective: Computed tomography (CT) virtual bronchoscopy is a noninvasive technique that provides an internal view of trachea and major bronchi by three-dimensional reconstruction. The aim of this study was to investigate the usefulness of virtual bronchoscopy in the evaluation of suspected foreign body aspiration in children. Materials and methods: Twenty-three children (12 girls, 11 boys) with a mean age of 2.4 years (8 months–14 years) who were admitted to emergency room with a suspicion of foreign body aspiration were included in this study. Chest radiograms, spiral computed tomography scans and virtual bronchoscopy images were obtained. Then, rigid bronchoscopy was performed within 24 h. Results: CT virtual bronchoscopy and conventional bronchoscopy revealed the location of the foreign body in seven patients. It was in the right main bronchus in four patients, in the right lower lobe bronchus in one patient, and in the left main bronchus in two patients. There was no discordance between two modalities. CT examination revealed hyperaeration of the ipsilateral lung in four patients, hyperaeration of the ipsilateral lung and mediastinal shift in one patient and bronchiectatic changes in one patient. CT detected no additional finding in one patient with a foreign body in the right main bronchus. In 10 of 16 patients without foreign body, CT examination demonstrated atelectasis, infiltration, peribronchial thickening, and paratracheal lymphadenpoathy. Conclusion: Helical CT scanning with virtual bronchoscopy should be performed in only selected cases with suspected foreign body aspiration. When the chest radiograph is normal and the clinical diagnosis suggests aspirated foreign body, helical CT and virtual bronchoscopy can be considered in order to avoid needless rigid bronchoscopy.

Although the precarinal space is critical in the interpretation of computed tomography (CT) of the thorax, vascular structures within the space have not been well documented. The aim of this study was to investigate vascular structures in the precarinal space that are detectable with contrast-enhanced CT scans. Contrast-enhanced CT chest scans from 90 patients aged 17-78 years (41 male, 49 female) were analyzed retrospectively. Twenty-two cadavers aged 54-93 years (13 male, 9 female) were used for gross anatomic study. We found that 9 of 90 cases of the contrast-enhanced CT scans had vessel-like structures detectable in the precarinal space, located primarily anterior to the right main bronchus. Single or double arteries were identified in the precarinal space of 19 cadavers. Thirteen of the 23 arteries observed were the right bronchial artery and 10 were the left bronchial artery. In two cadavers, a single right bronchial artery (2.5 and 4.0 mm in diameter), which could have been detected with contrast-enhanced CT, originated from the aortic arch and the root of the left subclavian artery and coursed in the precarinal space. Based on the variation in the location and size of the bronchial arteries observed in this study, we suggest that vascular structures are detectable in the precarinal space with contrast-enhanced CT, particularly anterior to the right main bronchus.

We would like to present a case of persistent right sided collapse in a preterm baby with an unexpected diagnosis. Baby X was born floppy requiring resuscitation and was intubated, ventilated and was transferred to NICU. There was decreased air entry on auscultation of right side of the chest, while the rest of the examination was normal. The chest X-ray showed right side white-out suggestive of collapse consolidation. She required significantly high ventilatory pressures to maintain saturations and chest X-ray performed on day 4 remained unchanged with persistent right sided white-out. The CT scan of the chest showed no definable right lung, right pulmonary artery or right main bronchus. The diagnosis of right lung agenesis with single pulmonary artery was made and baby was found to have more congenital malformations on further investigations, and later developed complications leading to palliative care.

WOS: 000308138900006 PubMed: 22916785 A 41-year-old woman came to our clinics describing increased cough and shortness of breath. A chest roentgenogram revealed a loss of volume in her right lung. Computed tomography revealed a lesion at the level of the main carina, clogging the right main bronchus almost totally. The lesion underwent biopsy by use of flexible bronchoscopy. Histopathologic evaluation showed that the specimen was a hypertrophic seromucous salivary-type gland. Total excision of the mass was performed by bronchotomy through a right thoracotomy. We describe this case of a hypertrophic seromucous salivary gland in the tracheabronchial system. (Ann Thorac Surg 2012;94:e73-5) (C) 2012 by The Society of Thoracic Surgeons

We report the case of a 52-year-old man who presented with a 2-week history of dyspnea and wheeze. CT scan of the chest showed a large soft-tissue lesion in the right main bronchus extending into the trachea. Pathologic examination of endoscopic tracheal biopsies showed features consistent with a non–small-cell lung carcinoma. 18F-FDG PET/CT showed very high uptake of FDG in the bronchial tumor (high standardized uptake values: 25.1) and unexpected very intense uptake in the left adrenal gland (high standardized uptake values: 62.5). Laparoscopic adrenalectomy was performed, and subsequent histopathological examination confirmed metastatic non–small-cell carcinoma in the adrenal gland. Although adrenal malignancies are generally metabolically active, such high uptake of FDG within a metastatic lesion has not been reported previously.

An 18-year-young male patient came to the emergency department with history of severe blunt trauma. He was having respiratory distress and diagnosed as bronchial injury on the right side. A chest tube was put immediately and there was continuous air leak in the form of air bubbles in the intercostal chest tube bag with each inspiratory effort. Chest injury can be a life-threatening condition, if not managed timely and properly. Bronchoscopy showed injury over the right main bronchus. The features of this uncommon entity are discussed, with special emphasis on early diagnosis and surgical management.

Inhalation of foreign bodies, a leading cause of accidental death, is most common in preschool children. In this article we report our experience with a 5-year-old Greek girl who presented with a 24-hour history of sore throat, chest pain, and shortness of breath. Emergency bronchoscopy was performed and multiple small chewing gummi bear (HARIBO) particles impacted in the orifices of the right main bronchus and right lobar and segmentalinic bronchi were successfully removed and aspirated. Aspiration of gummi bears, which is for the first time reported, may cause a silent choking episode leading to life-threatening bronchi obstruction at multiple sites, even in children older than 4 years.

Tracheostomy is a common airway procedure for life support. This procedure is safe, although occasional early and late complications are known to occur. Fracture and hence aspiration of a tracheostomy tube in the tracheobronchial tree is a rare late complication, which can be potentially life threatening. Published reports of a fractured tracheostomy tube presenting as a foreign body in the tracheobronchial tree are few. The most common dislodged sites reported were the trachea and the right main bronchus, the inner flange in our patient was lodged in the trachea and the left main bronchus. Foreign-body aspiration is a serious medical emergency demanding timely recognition and prompt action as was successfully done in our patient. Therapeutic rigid bronchoscopic removal is the mainstay of treatment. A periodic review of the techniques of tracheostomy care including timely check-ups for signs of wear and tear can possibly eliminate such avoidable late complications.

Introduction Helium magnetic resonance imaging ( 3 He MRI) provides functional information on lung ventilation, perfusion and microstructure. We describe use of 3 He MRI to assess lung function in a patient with “horse-shoe” lung. Case presentation EB is a 46 year old female with congenital lung abnormalities diagnosed during infancy. Chest x-ray confirmed an abnormal right upper lobe (RUL). Pulmonary arteriography reported hypoplastic RUL vessels. Bronchoscopy confirmed tracheal stenosis, and cardiac catheterisation reported an abnormal pulmonary arterial pattern. A diagnosis of congenital lung anomalies along with asthma was made during her childhood. Throughout her life her condition has been characterised by recurrent severe respiratory tract infections requiring hospitalisation. Recent CT chest confirmed right lung hypoplasia a deformed right main bronchus, moderate hypoplasia of the right main pulmonary artery and severe hypoplasia of RUL pulmonary vessels. An isthmus joins the two lungs consistent with “horse-shoe lung”. 1 Ventilation-perfusion scan reported 26% functioning right lung. Bronchoscopy confirmed tracheal and right main stem stenosis with left main stem bronchomalacia. Surgical resection is an option for ‘horse-shoe ‘lung characterised by recurrent infections. 2 In this context, we proceeded to 3 He MRI to obtain more detailed functional information. Results of 3 He Functional MRI Communication between the right and left lungs was visualised (Figure 1). In the right lung, ventilation was reduced with increased heterogeneity (Figure 1a, f). And perfusion notably reduced, in the RUL (Figure 1c. 3 He apparent diffusion coefficient (ADC), which estimates acinar airway dimensions, was elevated and heterogeneous (Figure 1c), consistent with hypoplasia. The left lung was well ventilated and perfused with normal ADC values. Conclusion 3 He MRI shows promise in functional analysis of “horse-shoe” lung with hypoplasia. This can prove useful in surgical assessment of these patients and therefore improve their management. References 1 Dikensoy O, Kervancioglu R, Bayram NG, Elbek O, Uyar M, Ekinci E. Horseshoe lung associated with scimitar syndrome and pleural lipoma. J Thorac Imaging 2006; 21 (1):73–5 2 Orzan F, Angelini P, Oglietti J, Leachman RD, Cooley DA. Horses lung: report of two cases. Am Heart J 1977; 93 (4):501–5

THERE IS AN ongoing debate as to whether a right-sided double-lumen tube (DLT) should be routinely used in thoracic surgery. The word routine is stressed to distinguish from special situations. The first design of the DLT in 1949 by Carlens1 was designated for left main bronchus intubation.2,3 The takeoff of the right upper lobe (RUL) near the carina made it impossible for the right mainstem bronchus to accommodate the tube without RUL occlusion. Several years later, a DLT was designed by White for right mainstem intubation. The Robertshaw4 design has a ventilating port for the RUL, and the right endobronchial cuff is S-shaped, allowing the RUL ventilation slot to ride over the RUL orifice. In the left main bronchus, the distance between the carina and takeoff of the left upper lobe orifice is adequate to accommodate the tip of the bronchial lumen without occluding the left upper lobe orifice. That distance varies between men and women and has been extensively described by Benumof et al.5 In their study, the distance was determined to be between 5 and 6 cm in women and between 6 and 8 cm in men. In the right main bronchus, the distance between the RUL orifice and the carina is short, and there is a narrow margin of safety. Although there is wide anatomic variation of the distance, most often it is between 1 and 2 cm from the carina. In some cases, the takeoff is adjacent to the orifices of the middle and lower lobes.6-8 In addition, the takeoff of the RUL orifice may often be at the level of the carina or at the trachea. Adequate ventilation requires proper positioning of the DLT with the ventilation slot opening directly into the RUL bronchial orifice. This positioning may be difficult and time-consuming to achieve and is prone to a high incidence of RUL occlusion. It often requires multiple manipulations and tube rotations until the right-sided DLT adequately aligns with the RUL orifice. Fiberoptic confirmation requires a skilled and experienced operator and does not guarantee the absence of intraoperative dislocation resulting from surgical manipulation or changes in patient position. Positioning of the RDL tube blindly, without the use of fiberoptic bronchoscopy, is unacceptable.9-14 Clinical assessment of breath sounds of the RUL is difficult to appreciate, and it is not surprising that the right-sided DLT has low popularity among practicing anesthesiologists. To avoid the problems associated with right-sided DLTs, most clinicians select left-sided DLTs for procedures on the left and right sides. Fig 1 summarizes the issues of concern when a right-sided DLT is used and why, in the author’s opinion, it should not be routinely used during thoracic surgery.

気管・気管支断裂損傷は, 鈍的胸部外傷の中で頻度は少ないが, 致命率は高い.われわれは, 受傷初期の胸部単純X線写真が診断に有用であった, 18歳男性のバイク外傷による右主気管支断裂損傷 (日本外傷学会, 気管, 気管支損傷分類Ib) の1例を経験した.胸部単純X線写真上, tracheobronchial stripeの描出, 進行性の縦走する気管と右主気管支周囲の透亮像, continuous diaphragm sign, 右側のNaclerio's V-signを認め, これらは縦隔気腫を示唆する所見であった.さらに, 奇静脈近傍の右主気管支陰影は不鮮明化し, その外側に血腫像を認めた.以上の所見から右主気管支断裂損傷が示唆された.手術は損傷部位を直接縫合閉鎖し, 救命した.

Rationale: Airway stenting is a well-established method that relieves symptoms and maintains airway patency in patients with airway obstruction. Serious complications caused by airway stents such as stent dislocation and airway obstruction during surgery are life-threatening. Patient concerns: An 80-year-old man was treated with bronchial stent for left bronchus obstruction caused by metastatic esophageal cancer. During tracheostomy surgery, he suffered from acute tracheal obstruction caused by dislocated bronchial stent. Diagnoses: Esophageal cancer, left bronchus obstruction, respiratory failure, tracheal obstruction. Interventions: Threading a 5.0-sized endotracheal tube combined with an Eschmann tracheal tube introducer to prop up the collapsed stent. Outcomes: The bronchial stent was re-expanded and threaded into right main bronchus and ventilation restored. Lessons: Patient with airway stent undergoing surgery with airway involved should be performed under the support of a backup physician and equipment that are capable of handling potentially life-threatening complications of airway stent. If not, in the emergent situation of tracheal obstruction due to tracheal/bronchial stent, protruding through the stent with a suitable, small-sized endotracheal tube with Eschmann tracheal tube introducer may be an alternative skill for saving life weighted with possible complications.

Aim To determine the efficacy of dual Y-shaped covered airway stents to treat thoracic stomach–right main bronchus fistulae. Material and methods Fifteen patients who developed thoracic stomach–right main bronchus fistula after oesophageal cancer resection and postoperative irradiation were retrospectively analysed. All fistulae were close to the right upper lobe bronchus. Two Y-shaped covered airway stents were designed for each patient. Under radiographic guidance, one stent was placed from the right main bronchus into the bifurcation of upper lobe and intermediate bronchus, the other was placed from the trachea into both main bronchi. Results All fistulae were closed immediately after stenting. All patients could eat a semi-solid diet. The symptom of coughing while lying down resolved in all patients, and no complications, such as airway bleeding or pneumothorax, occurred. The average survival time was 26.65 months (range 2–40 months, 11 patients were still alive at the study end). Two patients died of tumour recurrence. Another two patients died of pulmonary infections. In one of these patients, there was a long delay between symptom onset and stenting. In the other patient, a small rupture occurred in the silicone membrane covering the stent, which allowed the leakage of gastric contents into the lung. Conclusion Dual Y-shaped covered airway stent placement is feasible and safe to treat thoracic stomach–right main bronchus fistulae. Improvements to the material covering the stents is required.

Tracheobronchial injury is very challenging in diagnosis and treatment. Highly suspicious airway injury and early diagnosis is recommended. We present a case of 39 years-old woman suffering from acute respiratory failure with bilateral hemo-pneumothorax and diffuse subcutaneous emphysema initially. She weaned from ventilator a few days later, but dyspnea recurred due to delayed diagnosis of complete disruption of right main bronchus. However, the image study was incompatible with clinical findings. It showed collapse of left lower lung and hyperinflation of right lung, instead of right pneumothorax or fallen-lung sign. Under the assistance of veno-venous extracorporeal membrane oxygenation, primary repair of right main bronchial injury was performed successfully. Finally, she recovered well uneventfully. In tracheobronchial injury, early diagnosis is a positive prognostic factor. The other important point is primary repair, instead of lobectomy or pneumonectomy.

Iatrogenic lung collapse due to complete main stem bronchus obstruction caused by recurrent intubations and repetitive tracheal toileting has been rarely reported in literature. The early diagnosis and proper management are imperative to avoid mortality. A 1-month-old male child, weighing 3 kg, developed a complete right main bronchus obstruction caused by granulation tissue, after multiple intubations and prolonged pediatric Intensive Care Unit ICU care, leading to a complete right lung collapse. Removal of the granulation tissue was complete and successful using rigid bronchoscopy and forceps. Careful atraumatic intubation should be attempted in all patients with extra care in the neonatal age group. An experienced doctor or experienced attentive pediatric ICU nurses should handle the bronchial suctioning of neonates to avoid trauma to the tracheal structures. A bronchial obstruction that may result in lung collapse should be suspected after traumatic or prolonged intubation with frequent airway suctioning, where the early diagnosis and proper management are imperative to avoid mortality.

A 20 year old patient who was referred as a case of pyo-pneumothorax following blunt trauma sustained 3 months ago was found to have complete bronchial transection of the right main bronchus. He was taken up for surgery and after decortication; the two ends of the bronchus were re-anastomosed. The lung expanded fully and the patient had an uneventful postoperative course.

Although lung metastasis is frequent, endobronchial metastasis (EBM) is rare. We are presenting a case of colon cancer related bilateral EBM since it is rare. A sixty-two year old male patient was admitted with complaints of cough, respiratory distress and haemoptysis continuing for 3 months. He had a history of smoking 40 packages in a year, an operation due to colon cancer 12 years previously and adjuvant chemotherapy. Right pulmonary aeration was not observed in the direct pulmonary graphy, homogeneous opacity was detected in the right hemithorax and deviation to right was observed in the trachea. Fiberoptic bronchoscopy (FOB) revealed an endobronchial tumoral lesion obstructing the right main bronchus and tumoral lesions in the left main bronchus and the bronchus of the inferior left lobe. It was observed in an immunohistochemical study of the biopsy material, obtained from the mass within the right main bronchus, that the tumor sites were stained with CK20 and CDX2, and not stained with CK7 or TTF1. Histopathological findings were evaluated and found to be compatible with colon adenocarcinoma metastasis. Paliative 3600 cGY radiotherapy (RT) was performed on the right lung and mediastinum. FOLFIRI-Setuximab therapy was started since the metastatic colon cancer was of the K-ras wild type.

Background Bronchial avulsion is a serious complication of blunt chest trauma, which can be easily missed on initial presentation of a patient with multiple injuries. Missing the diagnosis may increase the risk of mortality and morbidity. Methods We evaluated the outcome of 10 patients with bronchial injury following blunt chest trauma, who underwent bronchial anastomosis in Quaem Hospital, Mashhad, Iran and Imam Khomeini Hospital, Tehran, Iran, from 2001 to 2012. There were 8 men and 2 women with a mean age of 23.1 ± 4.72 years. Associated injuries were ruled out in all cases. Demographic characteristics, anatomical location of the injury, mechanism of injury, complications of bronchial anastomosis, and one-year follow-up of the patients were studied. Results Eight patients had injury to the right main bronchus and 2 had injury to the left main bronchus. The time between surgery and diagnosis ranged from immediately to 6 months after injury. One death occurred in the operating room immediately after injury, due to asphyxia. The other 9 patients underwent successful anastomosis of the avulsed bronchus. There were 7 complications after repair, which were managed by a conservative approach. In one year of follow-up, one patient with residual stenosis underwent stent placement. Conclusion Early diagnosis of major airway injury is an important factor in successful management and a favorable outcome. With improvements in surgical technique, regular follow-up, and effective management of complications, we can expect successful bronchial repair to save the lung, even with a late diagnosis.

An 18-year-old woman was evaluated for a chronic productive cough and dyspnea. She was subsequently diagnosed with mediastinal non-Hodgkin lymphoma (NHL). A covered self-expandable metallic stent (SEMS) was implanted to relieve narrowing in for both main bronchi. The NHL went into complete remission after six chemotherapy cycles, but atelectasis developed in the left lower lobe 18 months after SEMS insertion. The left main bronchus was completely occluded by granulation tissue. However, the right main bronchus and intermedius bronchus were patent. Granulation tissue was observed adjacent to the SEMS. The granulation tissue and the SEMS were excised, and a silicone stent was successfully implanted using a rigid bronchoscope. SEMS is advantageous owing to its easy implantation, but there are considerable potential complications such as severe reactive granulation, stent rupture, and ventilation failure in serious cases. Therefore, SEMS should be avoided whenever possible in patients with benign airway disease. This case highlights that SEMS implantation should be avoided even in malignant airway obstruction cases if the underlying malignancy is curable.

Tracheoesophageal puncture (TEP) and voice prosthesis insertion is presently the preferred method of choice for voice rehabilitation following total laryngectomy in the management of advanced laryngeal cancers.[1, 2] This procedure involves the creation of a fistula between the trachea and esophagus, wherein a one way speaking valve containing silicon voice prosthesis is positioned. The patient is then trained to use and maintain the voice prosthesis by following a protocol for speech rehabilitation under the supervision of a speech therapist. This procedure is generally considered safe although occasional early and late complications are known to occur. The early complications are usually related to technique of insertion and include bleeding, edema, infection and salivary leakage around the prosthesis. The late complications include salivary leakage, fungal infection (usually Candida), granuloma formation around the prosthesis and rarely dislocation/aspiration of the prosthesis. A 55-year-old adult presented to our emergency services complaining of intractable cough resulting from the aspiration of the food contents through the TEP fistula site. Six months prior, he had undergone a total laryngectomy and primary voice prosthesis (Provox1) insertion for carcinoma larynx. (Stage pT4aN1M0) He was intermittently using a non-cuffed portex tracheostomy tube through his narrowed permanent trachoestoma following adjuvant radiotherapy. On admission, the patient was haemodynamically stable, clinical examination on removal of the tracheostomy tube showed the absence of the voice prosthesis in the TEP site; interestingly the patient was unaware of the missing prosthesis until then. He had the habit of self-insertion of the tracheostomy tube and we presume that the prosthesis aspiration might have occurred during this maneuver. Auscultation of the chest revealed decreased breath sounds on the right lung base. A chest skiagram revealed a vague opacity in the region of the right main bronchus, a CT scan of the chest done subsequently confirmed the presence of the aspirated voice prosthesis in the right bronchus intermedius. A bronchoscopy revealed the voice prosthesis to be occluding the opening of the right middle and lower lobe bronchus (Fig. 1a and ​andb)b) The voice prosthesis was removed using a laparoscopic biopsy forceps after visualizing it with a parallelly placed 30 degree rigid telescope through the tracheostoma under topical anesthesia. (Fig. 2a and ​andb)b) A nasogastric tube was placed in the TEP site to facilitate enteral feeds and the patient was discharged the following day with a plan to insert secondary voice prosthesis. Fig. 1 a, A bronchoscopy revealed the voice prosthesis to be occluding the opening of the right middle and lower lobe bronchus. b, CT scan of the chest showing the presence of the aspirated voice prosthesis in the right bronchus intermedius Fig. 2 a and b: The instruments used for removal of the voice prosthesis: a Laparoscopic biopsy forceps and a 30 degree rigid telescope Prosthesis aspiration is a rare complication and to the best of our knowledge only about ten cases have been reported in the Medline literature.[1–5] This is usually believed to happen when patients self attempt to replace the prosthesis or following violent bouts of cough. The clinical presentation of prosthesis aspiration can be varied: some patient’s present with life threatening chocking while others have minimal symptoms or at times asymptomatic [3, 4]. In most cases, the diagnosis is evident on history, although at times trachesotomized patients may not recollect the event of aspiration. [3] The prosthesis is visualized as a ring shaped opacity on a chest skiagram. A computed tomography of the chest with virtual bronchoscopy may be helpful in ascertaining the exact position of the aspirated prosthesis. [4] The common site of lodgment of the aspirated prosthesis is the right main bronchus,[2] although cases of impaction in the left main bronchus have been reported. Prosthesis aspiration like any other foreign-body aspiration should be considered as a serious medical emergency demanding timely recognition and prompt action. A flexible bronchoscopy plays an important role in the definitive diagnosis and this can be therapeutic,[2] while in some cases the rigid bronchoscopy or its modification, as was done in our patient is necessary. A periodic review of the maintenance techniques of voice prosthesis and tracheostomal care can possibly eliminate such unusual complications.

PURPOSE We aimed to determine the feasibility, safety, and effectiveness of radiology-guided forceps biopsy and airway stenting in patients with severe airway stenosis. MATERIALS AND METHODS This study involved 28 patients with severe airway stenosis who underwent forceps biopsy between October 2006 and September 2011. Chest multislice computed tomography was used to determine the location and extent of stenosis. Sixteen patients had tracheal stenosis, two patients had stenosis of the tracheal carina, six patients had stenosis of the left main bronchus, and four patients had stenosis of the right main bronchus. Forceps biopsy and stenting of the stenosed area were performed under fluoroscopic guidance in digital subtraction angiography and the biopsy specimens were analyzed histopathologically. We contacted the patients via phone call and utilized a standardized questionnaire to determine their medical condition during a postoperative three-month follow-up. RESULTS The technical success rate of radiology-guided forceps biopsy was 100%. Biopsy specimens were obtained in all patients. Dyspnea was relieved immediately after stent placement. No serious complications, such as tracheal hemorrhage or perforation, mediastinal emphysema, or asphyxia, occurred. CONCLUSION Radiology-guided forceps biopsy and airway stenting can be used for the emergency treatment of severe airway stenosis. This method appears to be safe and effective, and it may be an alternative therapeutic option in patients who cannot tolerate fiberoptic bronchoscopy.