Nineteen patients were randomly assigned to receive double-blind administration of 1% lidocaine solution or 2% lidocaine solution for topical anesthesia for fiberoptic bronchoscopy. The total lidocaine dose in the 1% lidocaine group was 110.5±22.3mg (mean±S.E.) and in the 2% group, 294.9±96.6mg. The total lidocaine dose administered to the patients in the 1% group was significantly lower than that in the 2% group. In both groups, arterial O_2 saturation measured by oximetry before fiberoptic bronchoscopy was similar during bronchoscopy. It was shown by a questionnaire after bronchoscopy that patient discomfort during the examination was similar in both groups ; however, the patients in the 1% group felt slightly more comfortable than those in the group with 2% lidocaine spray. These findings suggest that we can use the 1% lidocaine solution for local anesthesia in fiberoptic bronchoscopy.

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We have experienced 7 cases (3.1%) of late bronchopleural fistulas after stapling (using RL), among 223 cases stapled from June of 1989 through December of 1993. Of these, five were primary lung cancers and there was one case each of lung aspergillus and bronchiectasis. Sweet's method was introduced for bronchial closure. The average time of onset was about 1 year, and all of them were free from complications of pyothorax. The loosening of staples was detected with examination of bronchofiberscopy in all cases. Fibrin glue or an adhesive agent was poured on the bronchial stumps through bronchofiberscopy in 4 cases, and oral antibiotics were given in 3 other cases. They were all cured. We found that staples became relaxed, so we must make a device to prevent bronchopleural fistula, such as the closure of bronchial stump with additional sutures.

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The patient was 69-year-old male who had bloody sputum 4 years after left upper lobectomy due to squamous cell carcinoma. As bronchoscopy revealed a tumor occluding the left bronchus, radiation therapy and endoscopic Nd-YAG laser were performed. For maintenance of bronchial patency, insertion of a Dumon stent was planned. But a distortion of the left bronchus due to the upper lobectomy made it difficult to use a rigid bronchoscopy. So we inserted the stent using the flexible fiberscope. The stent was pushed out by an intubation tube passed over the fiberscope. A balloon catheter passed through the working channel was inserted beyond the distal orifice of the stent. Adjustment of the stent position was easily achieved by with drawing the catheter with the balloon inflated. This method is useful in cases, in which it is difficult to use of the rigid bronchoscopy because of kinking or deformity of the bronchus.

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A 72-year-old man was admitted for further examination of an abnormal shadow on chest X-ray film. Chest X-ray and CT showed a nodular mass in the right lower lobe (S^6). The specimen obtained by transbronchial tumor biopsy revealed poorly differentiated carcinoma. Right lower lobectomy was performed on a diagnosis of large cell carcinoma. No pulmonary or lymph node metastasis was observed. Microscopic examination of the resected specimen, including various immunohistological stains, showed that this tumor resembled atypical carcinoid with a ball-like structure, but showed severe cytologic atypism. One year later, he was readmitted because of hemosputum. Bronchoscopic findings revealed endobronchial tumors in the wall of the truncus intermedius and left basal bronchus. The endobronchial tumors were thought to be metastatic lesions from primary lesion. He showed no response after chemotherapy and radiation therapy, and 3 years after surgery, died of respiratory failure due to endobronchial metastasis. This tumor would have had better prognosis because of no nodal and distant metastasis at the time of surgical resection, but the tumor acted in an aggressive biologic manner compared with atypical carcinoid. We concluded that the classification of neuroendocrine tumors in this case was very difficult and considered the possibility of its being a large cell neuroendocrine carcinoma.

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We reported a case of malignant lymphoma with bronchial involvement in a 39-year-old male patient. Seven months before the present admission, he received intensive chemotherapy because of the T-lymphocytic lymphoblastic lymphoma originated from his thymus. He entered complete remission, but relapsed in a leukemic state. Chest X-ray on present admission revealed enlargement of bilateral hilar lymph nodes and expansion of the superior mediastinal space. Chest CT-scan images showed that the tumor shadow appeared to wrap around the bilateral main bronchi. Bronchoscopy showed that bilateral main bronchi were constricted with multiple edematous submucosal nodules. Transbronchial biopsy specimens, which revealed findings consistent with prethymocytic lymphoblastic lymphoma, were positive for surface markers of CD7 and HLA-DR and negative for those of CD2, 4 and 8. However, it is well-known that lymphoblastic lymphoma frequently involves the mediastinum, this type of lymphoma may also easily invade the bronchi.

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Three cases of chronic eosinophilic pneumonia of unknown cause presenting difficulty in diagnosis were discussed. In these cases eosinophilic pneumonia was diagnosed by repeated bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB). Most specimens of TBLB showed alveolitis, fibrin in alveoli, intraalveolar organization and mild eosinophilia, but eosinophilic abscess was not seen. Therefore in these cases the diagnosis of eosinophilic pneumonia was confirmed by BAL differentials showing 50% or more eosinophils. In the cases showing mild eosinophilia, difficulty in the differential diagnosis between BOOP and eosinophilic pneumonia was discussed.

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This paper reports two cases of bronchial foreign bodies. The first case was a 4-year-old girl admitted to hospital because of productive cough and fever. Chest X-ray showed obstructive pneumonia of the left upper lobe. Bronchofiberscopy revealed a vegetable foreign body and granuloma obstructing the left main bronchus. It was thought that she had aspirated it more than two years ago according to her history. The second case was a 81-year-old man that came to the hospital because of aspirating food six hours previously. Emergency bronchofiberscopy showed that the right main bronchus was reddish and edematous and a piece of green bean was impacted from the truncus intermedius to the right basal bronchus. The green bean was removed easily with a balloon catheter and a basket catheter via bronchofiberscopy. Adult cases of bronchial foreign bodies are often reported to have underlying diseases but to this case there was no underlying disease and his advanced age is considered to be one of the causes. Bronchial foreign bodies can be easily diagnosed, but they can have various symptoms and signs, and secondary changes of bronchi may provide a clue to the diagnosis of long-standing foreign bodies.

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A 61-year-old woman was admitted with persistent chest X-ray findings supposedly due to pneumonia. Bronchoscopic examination, after recovery from the pneumonia, revealed a tiny, seemingly pulsatile slightly rough-surfaced tumor about 5mm in diameter on a membranous portion of the trachea just above the carina. After completing differential diagnosis from vascular diseases such as bronchial artery aneurysm by applying dynamic computed tomography (CT) of the lungs and bronchial arteriography, an injection of 99.5% ethanol into the tumor followed by forceps biopsy was performed. Pathological examination indicated spindle-shaped tumor cells with mild nuclear atypism proliferating in an interlacing pattern in the subepithelial layer and few mitotic figures in the nuclei. It was diagnosed as leiomyoma of the trachea. The tumor was removed completely with a further forceps biopsy. Some reports refer to the bronchoscopic characteristics of bronchial vascular diseases as presenting pulsation, smooth and taut surfaces with normal mucosa, elastic depression on compression with a tip of biopsy forceps and so on. We observed some such characteristics in our case, and we decided to perform dynamic CT and bronchial arteriography for safety prior to biopsy. Leiomyoma of the trachea and bronchus is an extremely rare disease. Less than 70 cases have been reported in Japan up to 1992. Recent technical developments seem to have made invasive operations considered redundant for the treatment of small leiomyomas of the bronchial tree such as that described here. Among such cases, to the best of our knowledge, this is the first case report of a leiomyoma of the trachea successfully treated by 99.5% ethanol injection.

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Intratumoral injection of pure ethanol via flexible bronchofiberscopy was performed in a 66-year-old man with obstruction of the trachea caused by polypoid squamous cell carcinoma. Marked effects were obtained. Intratumoral ethanol injection is relatively noninvasive and is considered to promising endoscopic treatment for obstructive polypoid lesions of central airways.

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A 15-year-old male was admitted with chest pain. His chest X-ray showed atelectasis of the right middle and lower lobes, and overinflation of the right upper lobe. Bronchoscopy revealed a polypoid tumor in the truncus intermedius and the biopsied specimen showed benign adenoma. Bronchoscopic Nd-YAG laser ablations (total 21, 300J) were performed, but failed to open the distal airway. Finally, he underwent right middle and lower lobectomy. The tumor originated from the right B^6 orifice and extended into the truncus intermedius and right middle lobe bronchus. Histological examinatioin showed low-grade malignant mucoepidermoid carcinoma. Some tumors extending intrabronchially, including this case, are not suitable candidates for the bronchoscopic Nd-YAG laser therapy, but preoperative evaluation is difficult.

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A tumor with a smooth surface which almost obstructed the right main bronchus was found in a 68-year-old man presenting with cough and dyspnea on exertion. Bronchoscopy and Nd-YAG laser vaporization under general anaesthesia were performed for diagnosis and reestablishment of the airway. Specimens obtained by bronchoscopic biopsy did not yield the definitive diagnosis. However, the appearance and mucinous fluid discharged from the tumor after laser treatment suggested that the tumor was an endobronchial hamartoma originating in the cartilaginous portion of the right upper lobe bronchus. Thoracotomy was performed 1 week after the procedure, and an endobronchial hamartoma as expected was resected successfully by bronchotomy. He was discharged without any symptoms. Management with Nd-YAG laser contributed to not only airway reestablishment but also to the diagnosis of the tumor and the planning of the operation.

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A 64-year-old male undergone right pneumonectomy 9 years ago because of lung cancer. Five years later bronchopleural fistula was treated by omentopexy. However, empyema caused by recanalization of the bronchopleural fistula recurred 4 years after the omentopexy. Reoperation was planned and remobilization of the grafted omentum with muscle flap closure was performed. The omentum, which had been sutured with the old layer at the previous omentopexy, was covered by a new layer, ill granulation tissue, and pyogenic membrane. Removal of the outer three layers provided mobilization of the omentum, and the bronchopleural fistula was closed by the mobilized omentum and muscle flaps. The possibility of omental mobilization was suggested by CT findings which showed sufficient omentum, fat tissue with a low density level, and the smooth surface of the surrounding tissue.

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A 56-year-old male case of squamous cell carcinoma of the lung underwent a right middle and lower lobectomy. On the 58th postoperative day, bronchopleural fistula was detected. Fibrin gluing was performed via a flexible fiberoptic bronchoscope, and the fistula was completely closed and controlled. This method of fibrin gluing is useful to close postoperative bronchopleural fistula without surgical intervention.

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A 82-year-old man was admitted for surgical treatment of esophageal carcinoma. After subtotal esophagectomy, bronchofiberscopic examination was performed to aspirate bronchial secretions. A polypoid lesion was discovered in the posterior wall of the truncus intermedius. The biopsy specimens showed squamous metaplasia covering loose connective tissue with infiltration of lymphocytes and plasma cells. There was no evidence of direct invasion of malignant cells in the bronchus. The polypoid lesion was removed by biopsies via the bronchofiberscope. The patient had no clinical symptoms caused by the polyp and no findings in the lung fields on the chest roentgenogram. As bronchofiberscopic examinations become more common more frequently at inflammatory polyps may be discovered an early stage.

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A 49-year-old man was admitted as an emergency case because of imminent asphyxia in January, 1990. He had undergone surgery and radiotherapy because of a mucoepidermoid carcinoma of the ethmoid sinus two years earlier. The distal trachea and the right main bronchus were severely stenotic and the left main bronchus was occluded by an endobronchial tumor, the histological diagnosis of which was metastatic mucoepidermoid carcinoma. Emergency Nd-YAG laser irradiation and subsequent radiotherapy succeeded in improvement of the airway stenosis. In spite of repeated laser treatment imminent asphyxia developed again in April, 1992. A Dumon stent was inserted in the distal trachea and then a Gianturco Z-stent was also implanted in the distal trachea, right main bronchus and truncus intermedius, resulting in a symptomatic improvement. Three-dimensional CT was useful for the placement of stents in the airway.

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A 71-year-old man presented with cough, sputum and general malaise 6 months after operation for esophageal cancer. Bronchofiberscopy demonstrated obstruction of the left main bronchus due to recurrent esophageal cancer. Bronchography using a non-turbid contrast agent (Iotrolan 300) accurately demonstrated the location and dimension of the bronchial tumor, and did not cause any adverse reaction. Bronchography using Iotrolan 300 when inserting stent may be useful in the treatment of bronchial stenosis, because it dose not obscure bronchoscopic vision and demonstrates the bronchial tumor clearly.

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We treated two patients with complete rupture of the cervical trachea and glottic fracture following blunt trauma. A 53-year-old male was admitted to a hospital for dyspnea following blunt trauma by a rope and complete rupture was diagnosed by bronchofiberscopy. A 35-year-old male was admitted for dyspnea following blunt trauma in a traffic accident and glottic fracture was diagnosed by bronchofiberscopy. In such cases the lumen should be reestablished by careful approximation of the mucosa and reduction of the cartilage displacement to maintain function. Our results suggest that early diagnosis by bronchofiberscopy and surgical treatment to maintain function are important to improve the quality of life.

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