Preoperative assessment in patients with postintubation tracheal stenosis

Background Postintubation stenosis remains the most frequent indication for tracheal surgery. Rigid bronchoscopy has traditionally been considered the technique of choice for the preoperative diagnostic assessment. However, this technique is not routinely available, and new techniques such as flexible videobronchoscopy and spiral computed tomography (CT) scan with multiplanar reconstructions have been proposed as alternatives to rigid bronchoscopy. The aim of this study was to compare these techniques in the diagnostic assessment of patients with tracheal stenosis submitted to surgical treatment. Methods Twelve patients who underwent airway resection and reconstruction for postintubation tracheal and laryngotracheal stenosis were preoperatively evaluated with rigid and flexible bronchoscopy and with spiral CT scan with multiplanar reconstructions. The following parameters were examined: involvement of subglottic larynx, length of the stenosis, and associated lesions. The results were compared with the intraoperative findings. Results The accuracy of rigid bronchoscopy, flexible bronchoscopy, and CT scan in the evaluation of the involvement of subglottic larynx was, respectively, 92%, 83%, and 83%. The evaluation of the length of the stenosis was correct in 83%, 92%, and 25% of the patients, respectively, with rigid bronchoscopy, flexible bronchoscopy, and CT scan. A significant correlation was observed between the length of the stenosis measured intraoperatively and preoperatively with rigid (p < 0.001) and flexible bronchoscopy (p < 0.05) but not with CT scan (p = 0.08). The three techniques correctly showed the presence of an associated tracheoesophageal fistula in two patients, but CT scan did not correctly show the exact location of the fistula in relation to the airway. Flexible bronchoscopy was the only effective technique in the assessment of laryngeal function. Conclusions Rigid bronchoscopy remains the procedure of choice in the evaluation of candidates for tracheal resection and reconstruction for postintubation stenosis, and it should be available in centers that perform surgery of the airway. Flexible bronchoscopy and CT scan have to be considered complementary techniques in the evaluation of laryngeal function and during follow-up.     

Cryotherapy of subglottic hemangioma

The natural history of the hemangioma is spontaneous regression; therefore, most lesions require no treatment. The large occlusive subglottic hemangioma which presents before the age of 6 months, however, may be life-threatening. Two infants with subglottic hemangiomas with complete upper airway obstruction were treated successfully with cryotherapy, after tracheostomy. In each case the cryoprobe was placed transbronchoscopically on the subglottic hemangioma at -80 degrees C. for 30 to 45 seconds, the freezing interval varying with the age of the patient. One infant is asymptomatic and has had the tracheostomy tube removed. The other infant, after successful cryosurgical treatment, died from an unrelated illness. The histopathology of the larynx 3 1/2 months after cryotherapy of the hemangioma showed tracheal reepithelialization, active regeneration of cartilage with maintenance of luminal diameter, minimal submucosal fibrosis, and minimal residual hemangioma. Cryotherapy for subglottic hemangiomas offers many advantages including hemostasis, controlled local surgical injury, subsequent rapid healing of tissues with minimal fibrosis, and preservation of lumen without stricture. Previous forms of therapy which have been supplanted include radiotherapy, injection of sclerosing substances, systemic steroids, and surgical excision. Carbon dioxide laser is an effective therapeutic modality that we reserve for selected smaller hemangiomatis lesions of the subglottic area.     

胃嗜酸性肉芽肿26例报告

目的　进一步探讨胃嗜酸性肉芽肿的诊断与治疗。方法　对 2 6例胃嗜酸性肉芽肿的临床资料进行回顾性分析。结果　钡餐检查 19例 ,诊断胃溃疡 11例 ,胃癌 8例。胃镜检查 14例 ,诊断胃溃疡 8例 ,胃癌 4例 ,胃嗜酸性肉芽肿 2例。外周血中嗜酸粒细胞增多 10例。术中快速病理检查确诊 11例。行胃大部切除术 16例 ,胃癌根治术 10例。 2 3例随访 0 5～ 18年 ,无复发病例。结论　胃镜活检及术中快速病理检查可确诊嗜酸性肉芽肿 ,胃大部切除术是其主要的治疗方法。     

Successful treatment of postintubation subglottic stenosis with intralesional steroid injections

Traditional methods of managing postintubation subglottic stenosis include repeated dilation and various surgical procedures. None gives good results with any frequency. Encouraged by reported success with intralesional steroid injections for esophageal stricture, we successfully treated a patient with subglottic stenosis using steroid injections and dilations after a program of dilations alone had resulted in alarming clinical deterioration. The method merits further consideration.     

Repair of postintubation tracheoesophageal fistula in polytrauma patients

OBJECTIVE: We present our modest experience in treating tracheoesophageal fistula (TEF) in polytrauma patients where tracheal resection turns to be risky due to the size of the fistula and to the general condition of the patient. MATERIALS AND METHODS: Four polytrauma patients, three male and one female were treated at our department due to postintubation TEF. Confirmation was obtained endoscopically and radiologically. Surgical treatment consisted of identification and dissection of the fistulous tract and closure of the tracheal defect by transposing strap muscles and suturing them to the defect. Finally, the oesophageal defect was closed and a flap of sternocleidomastoid muscle was interposed between oesophagus and trachea. RESULTS: There was no intraoperative mortality. Three of our patients had an excellent result. The one who unfortunately returned to mechanical ventilation due to respiratory insufficiency developed a recurrent fistula. CONCLUSIONS: (1) Repair of postintubation TEF should be delayed until the patient is fully stabilised and weaned from ventilation. (2) Indirect closure of the tracheal defect with strap muscle transposition and sternocleidomastoid muscle interposition between oesophagus and trachea can be lifesaving.     

Partial cricoidectomy with primary thyrotracheal anastomosis for postintubation subglottic stenosis

OBJECTIVE: We describe a Pearson-type technique and evaluate its results for postintubation subglottic stenosis. METHODS: Forty-five patients underwent a partial cricoidectomy with primary thyrotracheal anastomosis, and 5 underwent simultaneous repair of a tracheoesophageal fistula as well. Twenty-four (53%) patients were referred to us after initial conservative (n = 21) or operative (n = 3) management. There were 27 cuff lesions, 7 stomal lesions, and 11 at both levels. The upper limit of the stenosis was 1.5 cm (range, 1-2.5 cm) below the cords, and the subglottic diameter was reduced by 60% in 38 (84%) of the patients. The length of airway resection ranged from 2 to 6 cm (median, 3 cm). Despite 23 thyrohyoid or suprahyoid releases, 8 anastomoses were under tension. RESULTS: Thirty-seven (82%) patients were extubated after the operation (n = 30) or within 24 hours (n = 7). Six patients required postoperative airway stenting (median, 5.5 days). Early (<30 days) complications occurred in 18 (41%) patients, mainly as transient airway and voice complaints, aspiration, and dysphagia. One (2%) patient died of myocardial infarction. Late morbidities were 2 failures occurring as bilateral recurrent nerve paralysis and restenosis requiring definitive tracheostomy. Patients had excellent or good anatomic (n = 42 [96%]), functional (n = 41 [93%]), or both types of long-lasting results, with no stenotic relapse. CONCLUSIONS: Partial cricoidectomy with primary thyrotracheal anastomosis can be applied in patients with postintubation stenosis extending up to 1 cm below the cords and measuring up to 6 cm in length with excellent-to-good definitive results. The association with a tracheoesophageal fistula does not contraindicate surgical repair.     

巨细胞修复性肉芽肿的诊疗分析及文献复习

目的:探讨巨细胞修复性肉芽肿的临床病理特征、诊断与治疗。方法:对3例巨细胞修复性肉芽肿患者(分别位于上颌骨、颞骨和上颌窦)的临床病理资料进行回顾性分析,并复习相关文献。结果:巨细胞修复性肉芽肿临床表现为局限性无痛性肿块,有时具有侵袭性。组织病理学特征为骨组织被纤维组织代替,多核巨细胞呈散在或灶性分布于纤维基质中。结论:巨细胞修复性肉芽肿是一种非肿瘤性病变,临床极为罕见,诊断有一定困难,需要结合临床和病理进行分析,彻底切除病变是有效的治疗方法。     

Long-term T-tube stenting as definitive treatment of severe acquired subglottic stenosis in children

Purpose

We analyzed our results of long-term T-tube stenting for severe acquired subglottic stenosis secondary to prolonged endotracheal intubation in a neonatal period.

Materials and methods

Twenty children treated with T-tube stenting since 1999 were retrospectively analyzed. T-tube stenting consisted of anterior cricoid split and placing silicon T-tube as a stent for expanded subglottic lumen.

Results

Fourteen of 20 patients were treated as an initial operation and 6 patients as an additional operation after other failed procedures. Decannulation was achieved in 8 (57.1%) of 14 children in the initial operation group and in 4 (66.7%) of 6 patients in the additional operation group. The average duration of T-tube stenting was 16.1 months in the initial group and 65.8 months in the additional group. Four of 20 patients continued to require T-tube stenting. In the other 4 patients, T-tubes were switched to tracheostomy tubes. The voice quality improved gradually after decannulation.

Conclusion

T-tube stenting for severe acquired subglottic stenosis is recommended as a best available treatment in postoperative quality of life. T-tube stenting should be performed as the initial treatment because the time to decannulation was shorter than as an additional operation.     

Intracranial plasma cell granuloma: A report of four cases

Inflammatory pseudotumors (IPT) are rare lesions composed of inflammatory cells admixed with collagen tissue. Although IPT are ubiquitous, intracranial locations are rare. In this study, four intracranial IPT of the plasma-cell-granuloma (PCG) type are reported. Four patients presented with lesions located, respectively, in the right cavernous sinus, the left cavernous sinus with extension to the tentorium cerebelli, the vermis cerebelli, and the pituitary stalk. All patients were operated on, but complete resection could not be achieved in cases 1 and 2. Follow-up was favorable in all cases, although case 1 still complained of headaches 2 years after operation. All cases were studied on histologic and immunohistochemical bases, and ultrastructural analysis was performed on two cases. In cases 1, 2, and 4, IPT were made up of plasma cells admixed with lymphocytes and rare histiocytes in a fibrous tissue —the density of which varied from case to case. In case 3, the mass was composed of plasma cells associated with numerous foamy histiocytes and polymorphonuclear cells. No light chain restriction could be demonstrated when immunohistochemistry was performed, and ultrastructural study did not disclose features reminiscent of meningioma or histiocytosis X. Intracranial IPT should not be confused with other diseases such as meningioma, lymphoproliferative disorders, or histiocytosis X. Although intracranial locations are much rarer than pulmonary ones, histology is identical in both sites and shows different patterns in its evolution. This is in agreement with the inflammatory origin of this lesion.     

微波治疗化脓性肉芽肿临床观察

目的：评估微波治疗化脓性肉芽肿的疗效和不良反应。方法：将79例化脓性肉芽肿患者随机分成微波治疗组39例和液氮冷冻组（对照组）40例,观察疗效和不良反应。结果：微波治疗组治愈39例,液氮冷冻组治愈29例,两组治愈率有显著性差异（P=0.000）;两组皮肤色素减退患者分别为1例和8例,发生微扁平瘢痕分别为6例和5例。结论：微波治疗化脓性肉芽肿简单、有效,可临床推广应用。     

脊椎嗜酸性肉芽肿（附14例报告）

报道经病理证实的脊椎嗜酸性肉芽肿１４例的治疗结果。其中１２例随访１～１８年，平均４年８个月，９例不全瘫痪者中，７例完全恢复，２例部分恢复；１例完全瘫痪者部分恢复。通过临床资料分析，着重阐述了脊椎嗜酸性肉芽肿的诊断和治疗方法的选择，认为有神经根或脊髓受压者，应以手术治疗为主，结合放疗或化疗；而无神经根或脊髓受压者，以放疗为主，结合化疗。早期诊断和正确的治疗是防止瘫痪发生的关键。     

Slide thyrocricotracheoplasty for the treatment of high-grade subglottic stenosis in children

Background/Purpose

The aim of this study was to describe our early experiences with a novel surgical procedure, “slide thyrocricotracheoplasty,” for the treatment of high-grade subglottic stenosis in children.

Patients and Methods

A retrospective analysis was performed in 7 children who underwent slide thyrocricotracheoplasty for high-grade subglottic stenosis from 1996 to 2009.

Results

Three patients were male and four were female. The etiology of subglottic stenosis was congenital (n = 4) or acquired (n = 3). All patients had undergone a tracheostomy before slide thyrocricotracheoplasty. Median age at operation was 16 months (range, 1-25 months). The median follow-up period after definitive operation was 58 months (range, 13-156 months). There was one case requiring debridement and re-anastomosis of slide thyrocricotracheoplasty site because of anastomotic disruption caused by a methicillin-resistant Staphylococcus aureus infection of the cartilage and one case requiring a minor operation to remove granulation tissue. At final follow-up, all patients did not have any airway cannulation with satisfactory functional outcome in terms of breathing and swallowing. All except one were noted to have acceptable vocal function. The patient with unsatisfactory vocal function continued to receive voice rehabilitation treatment.

Conclusions

Slide thyrocricotracheoplasty offers an efficient surgical treatment option with minimal morbidity for high-grade subglottic stenosis in children.     

Plasma cell granuloma of the hypothalamic region

Summary Two patients suffering from diabetes insipidus, with additional symptoms of impaired vision and signs of panhypopituitarism and increased intracranial pressure, showed a normal sella tursica in the X-ray examination of the skull but large, dense space-occupying lesions in the hypothalamus on CT scans of the brain. NMR performed in one patient disclosed suprasellar growth of a hypothalamic lesion. Proliferation of lymphoplasmocytes and mature plasma cells was seen by light microscopic and electromicroscopical examination of biopsy samples in both cases; histiocytes and multinucleated giant cells were absent; tuberculosis, syphilis and sarcoidosis were ruled out by appropriate tests. Plasma cells exhibited polyclonal immunoglobulin expression as revealed by immunocytochemistry using the PAP method. Taken together these features are typical of plasma cell granuloma. Transitory remission after radiotherapy was obtained in one patient.     

Solitary eosinophilic granuloma of the sternum

We report a rare case of eosinophilic granuloma of the sternum in a 25-year-old woman, who presented with anterior chest pain and a tender mass over the sternum. Total-body bone scintigraphy and computed tomography scanning of the thorax revealed an isolated lytic lesion of the manubrium. An open biopsy showed the typical histologic appearance of an eosinophilic granuloma. Surgical curettage of the solitary lesion was performed, and the sternal defect was filled with a bone replacement material. At the 2-year follow-up, no local recurrence was found, and the patient was in good health.     

Granular cell tumor mimicking a subglottic hemangioma

Pediatric airway tumors are uncommon. A 4-year-old girl with history of stridor since the first year of life underwent rigid laryngotracheal endoscopy revealing a left posterolateral subglottic mass occluding 80% of lumen. Complete tumor resection by open approach was undertaken. Histopathologic and immunohistochemical studies revealed granular cells tumor. The similarity of the clinical and endoscopic presentation of this tumor to the much more frequent subglottic hemangioma that usually requires a different therapeutic approach was of interest. Granular cell tumor must be considered in the differential diagnosis of upper airway obstructive symptoms in infancy and childhood.