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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 1  |  Issue : 1  |  Page : 15-16

Tracheal mass: A management challenge


1 Department of ENT and Head and Neck Surgery, Pratiksha Hospital, Guwahati, Assam, India
2 Department of ENT and Head and Neck Surgery, Nightingale Hospital, Guwahati, Assam, India
3 Department of Anaesthesia, Pratiksha Hospital, Guwahati, Assam, India

Date of Web Publication8-Nov-2017

Correspondence Address:
Nayanjyoti Sarma
Department of ENT and Head and Neck Surgery, Nightingale Hospital, Guwahati - 781 006, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aiao.aiao_2_17

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  Abstract 


A 58-year-old man presented with respiratory difficulty. He had a mass in the trachea arising from the left lateral wall and was totally obstructing the opening of the left main bronchus. This posed an anesthethic as well as a surgical challenge. The patient was managed, and the mass on Hewlett Packard Enterprise proved to be well-differentiated squamous cell carcinoma. He is doing well after 6 months following radiotherapy.

Keywords: Airway, bronchoscopy, tracheal mass, tracheostomy


How to cite this article:
Khaund G, Sarma N, Gogoi B, Agarwal V, Barman U, Gogoi D. Tracheal mass: A management challenge. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2017;1:15-6

How to cite this URL:
Khaund G, Sarma N, Gogoi B, Agarwal V, Barman U, Gogoi D. Tracheal mass: A management challenge. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2017 [cited 2019 May 24];1:15-6. Available from: http://www.aiaohns.in/text.asp?2017/1/1/15/217838




  Introduction Top


Tracheal masses could be benign or malignant. They usually present with respiratory difficulty. Masses that are high up can be managed by doing a tracheostomy below the level of the lesion; but when the mass is lower down [Figure 1], management of the airway poses a major challenge for both the surgeon and the anesthetist.
Figure 1: Rigid bronchoscopy image showing the tracheal mass preoperatively.

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  Case Report Top


A 58-year-old man presented with progressive dyspnea for 2 months. He did not suffer from hoarseness or dysphonia. He was treated elsewhere by physicians as chronic obstructive pulmonary disease. Computed tomography (CT) scan of the thorax was advised, and it revealed a soft tissue mass in the thoracic trachea just above the carina. The mass was totally obstructing the left bronchus and causing partial collapse of the left lung. Almost 80% of the tracheal lumen was obstructed by the mass. A bronchoscopy was attempted elsewhere, but the patient developed respiratory difficulty, and the procedure was abandoned.

We admitted the patient, and his airway assessed the same day in the operation theater (OT). Fiberoptic bronchoscopy was done with the anesthetist standing by. Both the surgeon and the anesthetist jointly visualized the mass and tried to formulate a strategy.

It was planned that we would do a tracheostomy first to help in accessing the mass. It was also planned that the anesthetist would intubate the right bronchus under flexible fibreoptic bronchoscopy guidance.

Unfortunately, the next day, before we could take the patient to the OT, he had an attack of hemoptysis, and his oxygen saturation dropped. Immediately, tracheostomy was done, and the patient was shifted to the OT. The subsequent procedure was done under general anesthesia with sevoflurane at 6% dial concentration with oxygen flow of 6 L/min and propofol 100 mg intravenous (IV) induction without muscle relaxant. The patient was kept in spontaneous ventilation. A small endotracheal (ET) tube was passed under endoscopic guidance per orally. Once the mass in the trachea was visualized with the endoscope and the gap between the mass and the tracheal wall was assessed, a no six cuffed ET was passed under direct vision by sliding along the right tumor-free tracheal wall. The position of the tube was confirmed by auscultation of the chest. The ET was further pushed by few mm, and the cuff was inflated. Auscultation was done, and when satisfied clinically (ventilation of the lung was adequate and the SpO2 was maintained at 92%–94%), muscle relaxant (atracurium) was administered IV and surgery commenced. The mass was removed piecemeal using laparoscopic forceps through the tracheostome. The left lung was collapsed preoperatively only, and the status was maintained intraoperative. Once the dissection of the tumor mass started in piecemeal manner, the ventilation in the left lung commenced spontaneously as the obstruction was gradually relieved. The patient was put in positive pressure mechanical ventilation for the next 12 h postoperative, using a larger ET tube. There was slight decreased air entry in the left lung in the postoperative period which was gradually improved by chest physiotherapy in subsequent days following the surgery.

The histopathological report showed well-differentiated squamous cell carcinoma. He was referred for radiotherapy. He was stable in the postoperative period [Figure 2] and the tracheostomy was closed after the completion of radiotherapy.
Figure 2: Flexible bronchoscopy image of the patient showing the trachea 5 months postoperatively.

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  Discussion Top


Primary tracheal masses are very rare and occur in 0.2/100,000 persons per year. Symptoms usually develop when the tracheal lumen is obstructed by the growth by 75% or more. These pose a threat to anesthesiologist so far as airway compromise is concerned.[1] Difficult intubation is also expected in other associated comorbid conditions such as anterior neck swellings, laryngeal edema, short neck, and obesity.[2],[3] Ventilation can be managed in different ways, including manual oxygen jet ventilation, high-frequency jet ventilation, distal tracheal intubation, tracheostomy, spontaneous ventilation, and cardiopulmonary bypass. The anesthesiologist and the team of surgeon should, therefore, have a joint approach in managing such cases since seepage of blood or tumor tissue into the distal tracheobronchial airway can further worsen the condition. If there are symptoms of respiratory distress such as stridor, orthopnoea urgent detailed evaluation by bronchoscopy, chest x ray, CT scan or MRI study is warranted.

In this context, it will be worth to mention about extracorporeal membrane oxygenation (ECMO). The use of ECMO has increased its popularity in recent years as a supportive measure in patients with respiratory and cardiac failure. Although it is used in the intensive care units in many hospital setups, it is rarely used as a means of support during anesthesia and surgery.

Radiotherapy is considered an ineffective primary treatment of malignant tracheal tumors.[4] Postoperative adjuvant radiotherapy after tracheal surgery is associated with a good long-term survival rate.[5] We referred our patient postoperatively for radiotherapy.


  Conclusion Top


In this case report, we stress the importance of securing a patent airway in patients presenting with intratracheal mass before surgical intervention is initiated. A well-planned tracheostomy can not only help in establishing a patent airway but also helps in resecting the intratracheal mass. Postoperative recovery could be smooth and uneventful.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Azorin J, Lamberto JF, Personne C, Larmignat P, Khellaf M, Kemeny JL, et al. Adenoid cystic carcinoma of the trachea. Treatment by combined laser therapy and surgery. Rev Mal Respir 1987;4:95-6.  Back to cited text no. 1
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2.
Farling PA. Thyroid disease. Br J Anaesth 2000;85:15-28.  Back to cited text no. 2
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3.
Lacoste L, Gineste D, Karayan J, Montaz N, Lehuede MS, Girault M, et al. Airway complications in thyroid surgery. Ann Otol Rhinol Laryngol 1993;102:441-6.  Back to cited text no. 3
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4.
Cheung AY. Radiotherapy for primary carcinoma of the trachea. Radiother Oncol 1989;14:279-85.  Back to cited text no. 4
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5.
Maziak DE, Todd TR, Keshavjee SH, Winton TL, Van Nostrand P, Pearson FG. Adenoid cystic carcinoma of the airway: Thirty-two-year experience. J Thorac Cardiovasc Surg 1996;112:1522-31.  Back to cited text no. 5
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