Mondello B

Spontaneous Pneumomediastinum: Experience in 18 Adult Patients

Spontaneous pneumomediastinum (SPM) is defined as the presence of air in the mediastinum, developing in the absence of traumatic, iatrogenic, or preceding pulmonary pathologies (emphysema, chronic bronchitis, and lung cancer). The aim of this study was to review our experiences with SPM, underlining its symptomatology, diagnosis, treatment, and followup, and defining a reasonable course of assessment and management. A retrospective case series was conducted to identify adult patients with SPM who were diagnosed and treated in our institution between 1998 and 2005. Eighteen patients (10 males) were identified (average age = 25 ± 4.8 years). Acute onset of chest pain was the predominant symptom at presentation. All patients developed clinically evident subcutaneous emphysema and underwent chest computerized tomography. Fiber bronchoscopy and echocardiogram were used selectively (8 patients). The average hospital stay was 6 (±1.4) days. Sixteen patients were conservatively treated, and only two patients were treated with thoracic drainage due to a related pneumothorax. The disease followed a benign evolution in all patients and, as of today, no relapse has been reported. SPM is an uncommon pathology with a usually benign course. The authors discuss SPM. A diagnostic algorithmic approach is necessary to rule out severe secondary entities and consequences that need urgent treatment.

Giant endobronchial hamartoma resected by fiberoptic bronchoscopy electrosurgical snaring

Less than 1% of lung neoplasms are represented by benign tumors. Among these, hamartomas are the most common with an incidence between 0.025% and 0.32%. In relation to the localization, hamartomas are divided into intraparenchymal and endobronchial.Clinical manifestation of an endobronchial hamartoma (EH) results from tracheobronchial obstruction or bleeding. Usually, EH localizes in large diameter bronchus. Endoscopic removal is usually recommended. Bronchotomy or parenchimal resection through thoracotomy should be reserved only for cases where the hamatoma cannot be approached through endoscopy, or when irreversible lung functional impairment occurred after prolonged airflow obstruction. Generally, when endoscopic approach is used, this is through rigid bronchoscopy, laser photocoagulation or mechanical resection. Here we present a giant EH occasionally diagnosed and treated by fiberoptic bronchoscopy electrosurgical snaring.

Surgical management of pulmonary inflammatory pseudotumors: a single center experience.

BackgroundThe pulmonary inflammatory pseudotumor (PIP) is a rare disease. It is still debated whether it represents an inflammatory lesion characterized by uncontrolled cell growth or a true neoplasm. PIP is characterized by a cellular polymorphism.MethodsWe retrospectively analyzed 8 patients with PIP treated by surgery between 2001 and 2009. Preoperative thoracic computed tomography (CT) scan was performed in all cases. All patients underwent preoperative bronchoscopy with washing and brushing and/or transbronchial biopsy and preoperative cytology examinationResultsThere were 5 men and 3 women, aged between 38 and 69 years (mean of 58 years). 3 patients (37%) were asymptomatic. The others had symptoms characterized by chest pain, shortness of breath and persistent cough or hemoptysis. 5 patients had neutrophilic leucocytosis. CT scan demonstrated solitary nodules (maximum diameter <3 cm) in 5 patients (62%) and lung masses (maximum diameter >3 cm) in 3 patients (37%). In 2 patients there were signs of pleural infiltration. Distant lesions were excluded in all cases. A preoperative histology examination failed to reach a definitive diagnosis in all patients. At surgery, we performed two lobectomies, one segmentectomy and five wedge resections, these being performed with videothoracoscopy (VATS), except for one patient where open surgery was used. Complete tumor resection was obtained in all patients. According to the Matsubara classification, there were 2 cases of organizing pneumonia, 5 cases of fibrous histiocytoma and one case of lymphoplasmacytoma. All patients were discharged alive from hospital between 4 and 7 days after surgery. At follow-up CT scan performed annually (range 11 to 112 months) (mean 58 months), there were no residual lesions, neither local nor distant recurrences.ConclusionsPIP is a rare disease. Many synonyms have been used for this disease, usually in relation to the most represented cell type. The true incidence is unclear. Preoperative diagnosis is difficult to reach, despite performing a bronchoscopy or a transparietal needle aspiration. Different classifications have been proposed for PIP. Either medical, radiation or surgical therapy has been used for PIP. Whenever possible, surgery should be considered the standard treatment. Complete surgical resection is advocated to prevent recurrence.

Thoracoscopic resection of a paraaortic bronchogenic cyst.

Bronchogenic mediastinal cysts (BMC) represent 18% of primitive mediastinal tumors and the most frequent cystic lesions in this area. Nowadays, BMC are usually treated by VATS. However, the presence of major adhesions to vital structures is often considered as an unfavourable condition for thoracoscopic treatment. The authors report the thoracoscopic treatment of a BMC having dense adhesions to the aortic arch. Diagnosis and surgical treatment is described. Review of the literature and surgical options on this topic are discussed.

Bronchial tree-shaped mucous plug in cystic fibrosis: imaging-guided management

We report the case of a 17‐year‐old boy with cystic fibrosis (CF) who presented with persistent cough; after starting intravenous antibiotics for Pseudomonas aeruginosa he underwent a computed tomography (CT) scan of the chest. CT revealed extensive consolidation in the right lower lobe with relative bronchus obstruction; the cause of bronchial obstruction was detected in the mediastinal window, corresponding to a bronchial tree‐shaped, thick, tenacious mucous plug. This was extracted 48 h after unresponsive bronchial washing and endobronchial instillation of rhDNAse, using foreign‐body forceps, with subsequent resolution of cough. This case, which is the second report of plastic bronchitis in CF, was resolved by mechanical removal of the mucous plug, suggesting that a careful observation of CT imaging may guide intervention aimed at resolution of atelectasis.

Management of a case of unacknowledged foreign body in the upper airway

Tracheobronchial foreign body aspiration occurs rarely in adults and may go unrecognized for a long time, but early detection and immediate retrieval of the foreign body are essential to prevent major morbidity. We describe the case of an adult who unusually aspirated part of his dental prosthesis during an attempted strangulation, which was unacknowledged until 6 months later when he was hospitalized with acute respiratory failure and required an emergency surgical tracheotomy. The foreign body was successfully removed via flexible bronchoscopy.