Francisco Navarro-Reynoso

Systematic review of spontaneous pneumomediastinum: a survey of 22 years' data.

Objective To describe and clarify management protocols in relation to spontaneous pneumomediastinum, and try to integrate criteria on this subject. Background Thoracic physicians are faced with patients who present with gas in the mediastinum, frequently without an obvious etiologic factor. Published material contains heterogeneous information from which different conclusions can be drawn. Methods In a Medline search from 1990 to 2012, we collected data on mortality, morbidity, signs, symptoms, etiologic factors, and diagnostic methods. Standardized mean differences were calculated. Results We identified 600 patients in 27 papers with series of >5 patients without precipitating or etiologic factors previous to the clinical presentation, but athletic activity, drug abuse, and history of asthma played an apparent role in the disease process. Most patients complained of thoracic pain and dyspnea, with subcutaneous emphysema and Hamman’s sign. The most common complication was tension pneumothorax. Morbidity was seen in 2.8%; no mortality has been reported so far. Conclusion Spontaneous pneumomediastinum is a rare disease with a benign course, which should be treated conservatively unless a complication mandates an invasive procedure. An algorithm for diagnosis and treatment is offered, based on the available evidence.

Descending necrotizing mediastinitis below the tracheal carina

Background Descending necrotizing mediastinitis is a dreadful disease with a high mortality rate, particularly when below the tracheal carina. This study describes the epidemiologic, clinical, and paraclinical features of patients treated for this condition. Methods We performed a single-center retrospective descriptive review of 60 patients with descending necrotizing mediastinitis below the tracheal carina, who were treated during a 7-year period, the largest study in the last 50 years. Demographic, clinical, paraclinical, and therapeutic variables were analyzed. Results 43 (71.7%) patients were male. The mean age was 41.2 ± 14.7 years. Mean hospital length of stay was 25.0 ± 19.8 days. Comorbidities were present in 46.7% of patients, diabetes mellitus being the most common. Odontogenic infections (45%) were the most frequent source of descending necrotizing mediastinitis. Cultures showed Gram-negative bacilli in 68.3%, Gram-positive cocci in 38.3%, and fungi in 6.7%. Mortality was 35% (21 patients); risk factors for mortality were age (>35 years), diabetes mellitus among other comorbidities, and associated complications. Conclusions In this low socioeconomic status patient population, descending necrotizing mediastinitis below the carina causes high morbidity and mortality, the latter particularly associated with age, complications, diabetes mellitus and other comorbidities.

Tracheal ring fracture and pseudomembrane formation after percutaneous dilatational tracheostomy.

To the Editor: Various complications from percutaneous dilatational tracheostomy (PDT) have been reported in the literature. Tracheal ring fracture can take place while either using single or sequential dilators during the procedure.1 Fibrinous tracheal pseudomembranes can also appear in previously intubated patient.2 Recently, we encountered a case in which both tracheal ring fracture and pseudomembrane developed as a consequence of PDT. A 36-year-old woman with a history of diabetes mellitus and postpartum dilated cardiomyopathy was admitted to intensive care unit (ICU) with decompensated cardiac failure. She required intubation because of acute pulmonary edema. On day 6, she developed ventilatorassociated pneumonia and on the 11th day, she underwent bronchoscopy-guided PDT. The procedure was performed by a thoracic surgeon using a single dilator technique (Blue Rhino; Cook Critical Care Inc.). There were no immediate complications. Moreover, there were no unusual findings during the insertion of the dilator and the tracheostomy cannula as evidenced endoscopically. The patient was disconnected from mechanical ventilation and discharged from the ICU 4 days later. To safely remove the tracheostomy cannula, a flexible bronchoscopy was performed on day 18. A fibrinous tracheal pseudomembrane was found above the tracheal stoma (Fig. 1A). It was removed using argon plasma coagulation through the flexible bronchoscope. Concomitantly, a segment of tracheal cartilage protruding into the tracheal lumen was evidenced (Figs. 1B, C). The cartilage was removed with the help of Kelly’s forceps introduced through the tracheal stoma (Fig. 1D). The tracheostomy cannula was successfully removed and she remained asymptomatic at 15-day, 1month, and 6-month follow-up. PDT is a common and relatively safe procedure.2 Prolonged intubation remains the most common indication. Complications from PDT could be encountered perioperatively or during the early or late postoperative period. Tracheal ring fracture is a perioperative complication that could occur while using single or sequential dilators. It could be un-noticed, despite bronchoscopic guidance during tracheostomy. Its incidence range from 5% to 36%1 and its long-term significance remains poorly defined.3 Tracheal pseudomembranes may appear in previously intubated patients shortly after the extubation and is considered a potentially fatal complication from sudden airway obstruction if undetected and not managed in a timely manner.4 It is usually located at the site where the tracheal tube cuff comes in contact with the tracheal mucosa. It is composed mainly of fibrin and desquamated necrotic epithelium. It could be permanently removed with a rigid bronchoscope or by means of flexible bronchoscopy techniques.4–6 In the presented case, both pseudomembrane and tracheal ring fracture were evidenced during bronchoscopic inspection performed before the removal of the tracheostomy cannula. In the beginning, extraction of the pseudomembrane with forceps through the flexible bronchoscope was not feasible because of its firm adherence to the tracheal wall, and the argon plasma use of coagulation was required. Removal of the piece of cartilage was possible with the use of Kelly’s forceps introduced through the tracheal stoma. In conclusion, tracheal ring fracture and postintubation tracheal pseudomembranes are not infrequent complications of the PDT, the latter being potentially fatal if not detected and treated in timely fashion. Bronchoscopic examination should be performed before decannulation for early detection and prompt management of PDT complications.

Descending necrotizing mediastinitis associated with spinal cord abscess

A 58-year-old man with a history of Ludwig’s angina was admitted with a spinal cord abscess at the level of C2-T1 and associated osteomyelitic destruction of vertebral bodies, spinal cord compression, and secondary quadriparesis, followed by descending mediastinitis. A right posterolateral thoracotomy and a cervicotomy drained purulent exudates. A tracheostomy was performed, and the patient was discharged after 84 days.

Ascending necrotizing mediastinitis secondary to emphysematous pyelonephritis

Mediastinal infections usually originate from postoperative complications or in a descending manner from a cervical infectious process; few reports have emerged describing an ascending trajectory. A 56-year-old woman with a Huang class 1 left emphysematous pyelonephritis was referred due to a progression of an ascending necrotizing mediastinitis. A left posterolateral thoracotomy was performed, drainage and thorough lavage were carried out with a successful outcome. We believe this is the first reported case of ascending necrotizing mediastinitis secondary to an emphysematous renal infection.

Endobronchial Embryonal Carcinoma.

Malignant tumors can compress or invade the trachea or bronchi leading to varying degrees of airway narrowing. Lung cancer is the most frequent cause of airway occlusion of neoplastic origin1 and also the leading cause of death among all the malignancies in the world.2 However, distant metastatic tu

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Descending necrotizing mediastinitis and sternoclavicular joint osteomyelitis

Descending necrotizing mediastinitis is usually associated with cervical or odontogenic infections. We describe a patient with blunt trauma to the chest 2 years earlier, and a slowly developing chest wall hematoma 18 months prior to admission, complicated by chronic sternoclavicular joint osteomyelitis, eventually leading to descending mediastinitis. Thoracotomy with drainage of the mediastinal spaces and multiple procedures for the sternoclavicular joint infection were successful. The rarity of this association and undefined optimal management prompted this report.

Benign tracheal stenosis: a case series analysis.

Tracheal stenosis (TS) requires a precise diagnosis and an experienced operator in both endoscopic and surgical treatment. We describe a case series at a tertiary care teaching hospital. Twenty patients with TS and/or subglottic stenosis were included. All underwent flexible bronchoscopy (FB). Spirometry (SP) was obtained in 8 patients, and helical computed tomography with three-dimensional reconstruction (HCT3D) was obtained in 11 patients. All cases were graded by each modality on a scale of 1 to 3, and the findings were correlated among modalities. Mean follow-up was 11.1 months (range: 3 to 47 mo). Postintubation injury was the most frequent cause of stenosis in 16 patients (80%). Mean stenosis grade±SD was 2.0±0.92 for SP, 2.3±0.86 for FB, and 2.54±0.68 for HCT3D. A significant correlation was found between HCT3D and FB (r=0.76, P<0.01). There was no correlation between SP and FB (r=0.46, P=0.2) or between SP and HCT3D (r=0.68, P=0.13). Treatment was conservative in 8 patients. Eighteen tracheal dilatation procedures were performed in 7 patients (mean: 2.5 dilatations/patient, range: 1 to 6; mean free time between dilatations 109.7±81 d, range: 6 to 210 d). Tracheoplasty was carried out in 7 patients, with tracheal anastomosis in 4 patients and thyroid-tracheal anastomosis in 3 patients. Tracheostomy was required in 1 patient with scleroma. Neither complications nor mortality related to FB was reported. HCT3D has a good correlation with FB. Tracheal dilatation is a viable option for patients who are not surgical candidates and for those with restenosis of tracheal anastomosis.