Pneumomediastinum due to tracheal foreign body ...

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cough, difficulty in breathing and hemoptysis. Signs of a tracheal mass can include stridor and wheezing. Fitzgerald et al. 4 reported a case of an intra-tracheal.
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The Journal of Laryngology & Otology Xxxxxxx 2005, Vol. 119, pp. 000–000

Pneumomediastinum due to tracheal foreign body granuloma H KISHORE CHANDRA PRASAD, MS, DLO, SUJA S SREEDHARAN, MS, SYDNEY D’SOUZA, MD*, NAVEEN KUMAR, MS, SAMPATH CHANDRA PRASAD, MBBS

Abstract Primary tracheal masses are rare. Secondary masses of the trachea are commonly foreign body granuloma, intubation granuloma or viral granuloma. The differential diagnoses given in such cases include both benign and malignant lesions. The otolaryngologist is often asked to perform a biopsy of the lesion to arrive at a diagnosis. However, even malignant processes can cause a granulomatous reaction. The timely diagnosis of tracheal masses depends upon maintaining a high index of suspicion. A rare case of tracheal granuloma leading to pneumomediastinum in a 53- year-old female is presented. The clinical features, investigations and treatment are detailed. The tracheal granuloma was managed by excision through bronchoscopy and the pneumomediastinum was managed conservatively. Key words: Granuloma; Pneumomediastinum; Trachea; Foreign Body

Introduction The incidence of primary tracheal neoplasms is estimated to be less than 0.2 per 100 000 persons per year.1 Some of the endotracheal masses that are rare are granulomata secondary to an inflammatory reaction. Any foreign particle that is implanted into the body will elicit an inflammatory response. The likelihood of granuloma formation depends on the nature of the foreign body, the site of implantation, and the host’s ability to mount an immune response.2 A granuloma is not a desired outcome and can cause chronic infection and airway obstruction. Bronchial granulomas are more common than tracheal granulomas. Very few cases of intra-tracheal granulomas are found in the available literature, and we did not come across any published cases of intra-tracheal granuloma leading to pneumomediastinum. We feel that our case merits attention.

raised above normal. Plain radiograph of the chest and neck showed no abnormality. A computed tomographic (CT) scan of the trachea and thorax showed a well circumscribed intraluminal tracheal mass located 3 cm above the carina causing tracheal obstruction (Figure 1). Air shadows were seen in the mediastinum (Figure 2) suggesting pneumomediastinum. From the above clinical and radiological findings, a diagnosis of a tracheal mass, leading to erosion of the trachea and subsequent pneumomediastinum, was made. The patient was admitted and put on broad-spectrum antibiotics. She then underwent rigid bronchoscopy which showed a pedunculated fleshy lesion 3 cm above the carina. A biopsy specimen showed inflammatory granuloma. After one week bronchoscopy was repeated; the granuloma was excised endoscopically. Trachea and bronchi were examined and there was no evidence of a foreign body or erosion of the tracheal wall. A specimen was sent for histopathological examination and fungal culture; it was identified as inflammatory granuloma with no evidence of malignant cells or fungus in the excised tissue (Figure 3). The patient received Cefotaxime (inj. 1 g i.v. tds) for 15 days after the excision of the granuloma. Pneumomediastinum was managed conservatively. On follow up, the patient has been symptom free for the past 13 months.

Case report A 53-year-old female presented to the outpatient department with complaints of persistent cough for 15 months, expectoration for six months and shortness of breath on exertion for three months. Before coming to us she was admitted to another hospital three times, and received many courses of antibiotics, steroids and bronchodilators. She gave a history of fever on and off during her illness. There was a history of three episodes of blood-stained sputum and she had halitosis. Her past history did not indicate bronchial asthma. General clinical examination showed a healthy appearing female. Auscultation of her chest revealed bilateral minimal basal crepitations and she also had a biphasic stridor. No neck nodes were palpable. The rest of the ENT examination was within normal limits. Her white blood cell count and erythrocyte sedimentation rate were

Discussion Intra-tracheal masses may go unrecognized until large enough to cause significant symptoms.3 It has been noted that 50–75 per cent tracheal obstruction is necessary before the onset of symptoms. In adults the possibility of malignant and benign tumors should also be considered. Squamous cell carcinoma, adenoid cystic carcinoma, chondroma, chondroblastoma and squamous papilloma are the most common primary tumors of the trachea.

From the Departments of Otolaryngology – Head & Neck Surgery and Internal Medicine*, Kasturba Medical College, Mangalore, Karnataka State, India. Accepted for publication: 21 April 2005. 1

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H K C PRASAD, S S SREEDHARAN, S D’SOUZA, N KUMAR, S C PRASAD

FIG. 3 Histopathology of the inflammatory lesion in the trachea.

FIG. 1 Axial CT scan showing circumscribed intra-tracheal granuloma.

Etiopathology The most common cause of an intra-tracheal granuloma is an intra-luminal foreign body. Fitzgerald et al.4 have described an intra-tracheal foreign body granuloma formation due to Marlex mesh splinting for tracheomalacia. After 11.5 years of external splinting of the trachea, the patient presented with foreign body granuloma. The edge of the mesh had eroded through the tracheal wall and was acting as a nidus for granuloma formation. Barben et al.5 reported a seven-year-old child with a bronchial granuloma in the left upper lobe bronchus due to a metallic foreign body. In our case the patient did not recall any obvious foreign body ingestion. Clinical features Tracheal masses present in three principal ways: signs and symptoms of upper airway obstruction, hemoptysis, and episodes of pneumonia.6 Symptoms are mainly cough, difficulty in breathing and hemoptysis. Signs of a tracheal mass can include stridor and wheezing.

FIG. 2 CT scan showing air shadows (thick arrows) in the mediastinum. Sternum and aorta (thin arrows) are seen.

Fitzgerald et al. 4 reported a case of an intra-tracheal foreign body granuloma in which the patient presented with shortness of breath on exertion, dry cough and audible wheeze. Barben et al.5 in their report of a case of bronchial granuloma due to foreign body described the presenting symptoms as a three-year history of recurrent cough and fever. They also described the signs and symptoms of foreign body inhalation and primary lung tumors. According to these authors, cases of foreign body inhalation usually present with cough, choking, fever, respiratory distress and wheezing; primary lung tumors usually present with hemoptysis, dysphagia, wheezing, cyanosis and weight loss; and hemoptysis is seen mostly in malignant tumors of the lung and less frequently in benign tumors. The presence of hemoptysis in our patient signifies that even benign lesions such as intratracheal granulomatous lesions can bleed and hence mimic malignancy. The expectoration, fever and halitosis could be secondary to collection of secretions and secondary infection in the bronchial tree due to the physical obstruction in the trachea. The breathlessness could be attributed to pnuemomediastinum and tracheal obstruction. Diagnosis After clinical examination the work up must begin with a hemogram and radiography of the airway. CT imaging of the neck and chest may define the intra-luminal extent of the lesion. Finally, a bronchoscopy and biopsy can clinch the diagnosis. Barben et al.5 stated that primary broncho-pulmonary tumors should always be considered in the evaluation of a bronchial granuloma in children even though they are uncommon. The diagnosis of an inhaled foreign body in most cases is straightforward, the history of aspiration being the key feature.5 Since this history was absent in our patient, the final diagnosis was pending till the biopsy following bronchoscopy proved the lesion to be an inflammatory granuloma. Treatment Endoscopic excision of the granuloma, as done in our case, is one of the methods of treatment. Barben et al.5 used a combination of oral corticosteroids and antibiotics for a bronchial foreign body granuloma in a seven-year-old girl. These drugs reduced the size of the granuloma and later it was endoscopically excised. Excision with CO 2 laser can also be used. Pneumomediastinum, a rare complication, requires surgical decompression.7

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CLINICAL RECORDS

Conclusion The otolaryngologist will rarely encounter an intra-tracheal inflammatory granuloma leading to pneumomediastinum. Regardless of histopathology, tracheal masses cause considerable morbidity due to their critical location. A CT scan should therefore always be considered in the evaluation of a tracheal granuloma. With endoscopic removal, preferably with a rigid bronchoscopy, followed by broad-spectrum antibiotics for 15 days for an intra-tracheal foreign body granuloma and conservative treatment for pneumomediastinum, patients should recover completely. References 1 Jackson C, Jackson C. Bronchoesophagology. Philadelphia: WB Saunders, 1950;199,208 {AQ1} 2 O’Hare TJ, Granulomatous and lymphoproliferative diseases of the head and neck. In: Thawley SE, Panje WR, eds. Comprehensive Management of Head and Neck Tumors. Philadelphia: WB Saunders, 1999; 1958 {AQ2} 3 Holinger PH, Novak FJ, Johnston LC. Tumor of the trachea. Laryngoscope 1950;60:1086 4 Fitzgerald, JM Walton et al. {AQ3} Intratracheal granuloma formation: A late complication of marlex mesh splinting for tracheomalacia. J Pediatr Surg 1996;31:1568–9

3 5 Barben J, Berkowitz RG, Kemp A, Massie J. Bronchial granuloma - where’s the foreign body? Int J Pediatr Otorhinolaryngol 2000;53:215–9 6 Mathisen DJ. Management of tumors of the trachea. In: Thawley SE, Panje WR, eds. Comprehensive Management of Head and Neck Tumors. Philadelphia: WB Saunders, 1999;1820–32 7 The mediastinum. In: Sabiston and Spencer, eds. {AQ4} Gibbons Surgery of the Chest, 4lh edn. Philadelphia: WB Saunders, 1983;408–9 Address for correspondence: Dr H Kishore Chandra Prasad, MS, DLO, First Floor, Nethravathi Building, Balmatta, Mangalore - 575001, Dakshina Kannada, Karnataka State, India. Fax: +91 824-2428379 E-mail: [email protected] Dr H K C Prasad takes responsibility for the integrity of the content of the paper. Competing interests: None declared

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AUTHOR QUERIES AQ1 199, 208 - just two pages cited? AQ2 1958? Please give page range for chapter cited. AQ3 Please provide names of first six authors. Is it JM Fitzgerald, or JM Walton? AQ4 Please provide author(s) of cited chapter, and initials of the Editors.