A total of 49 cases of stenotic type bronchial tuberculosis were observed macroscopically. Histologic examinations were made in 20 cases treated surgically. The number of female cases was more than double that of male cases. Symptoms indicating bronchial stenosis appeared 6 to 24 months after the start of chemotherapy and there were few tubercle bacilli in sputum in the majority of cases. Active tuberculous lecions were found in a few cases in the peripheral part of the stenosis, but in most cases the bronchial mucosa was replaced by fibrous tissue and showed stenosis with deformity and dislocation of the bronchial cartilages. Fibrosis of the bronchial wall occurred earlier and more markedly around cartilages, while it was slighter in the superficial mucosa where congestion and lymph edema were often observed. Bronchial glands showed hypertrophy and hyperplasia in the active inflammatory phase, and still remained abundantly in the mucosa between cartilages in the fibrotic stage. Implantation of tubercle bacilli into the duct lumen of the bronchial glands seemed to be an important early-stage type of tuberculous changes in solitary central bronchial tuberculosis. Probable onset of bronchial tuberculosis from adjacent hilar lymph node lesions was noted in 2 of 49 cases.

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Purpose : Diagnostic yields of bronchoscopic procedures for pulmonary tuberculosis were evaluated. Material : A total of 82 patients from whom acid-fast bacillus(AFB)smears of sputum were negative, or from whom no sputum could be obtained. (Patients diagnosed by clinical/radiographic criteria were included, but patients with bronchial TB were excluded from this study.) Results : While 29 patients(35%) had positive culture on bronchial samples alone, 13 patients(11%) had negative culture in bronchial samples but had positive culture in sputum collected prior to bronchoscopy. AFB smears of bronchial samples were positive in 30% of the total cases, and bronchoscopic procedures yielded positive culture in 51%. Nucleic acid amplification(NAA) tests on bronchial samples were positive in 16 of the 40 cases(40%). Transbronchial biopsy findings were compatible to tuberculosis in 5/9 cases(caseous necrosis or epithelioid cell granulomas). Bronchoscopy contributed to the early diagnosis of tuberculosis in 33 cases(AFB positive in 25, NAA positive in 7, histological in one). Conclusion : Overall diagnostic sensitivity was not high, although bronchoscopy for the diagnosis of pulmonary tuberculosis should be performed in consideration of the necessity to distinguish it from other diseases.

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For patients with suspected tuberculosis who do not produce sputum spontaneously or are smear-negative for acid-fast bacilli, the next procedure to be undertaken is bronchoscopy. The effectiveness of bronchoscopic examination for the diagnosis of pulmonary tuberculosis in our institute was retrospectively reviewed. Between October 1997 and September 2000, 101 bronchoscopic procedures for the diagnosis of tuberculosis were performed in patients without prior detection of the bacteria in their sputum. Of these, 34 cases were diagnosed as active tuberculosis. Among them, Mycobacterium tuberculosis was cultured from their first sputum in 10 cases(29.4%). The bronchoscopic method raised the detection ratio to 76.5%(26/34 cases), (p<0.001). The smear test of brushing or bronchoalveolar lavage fluid was positive in 15 cases(44.1%), allowing an early diagnosis. In 10 cases(29.4%), the bacteria were detected only by bronchoscopic methods. In 8 cases(23.5%), however, neigher sputum nor bronchoscopy could reveal bacteria. Therefore every clinical aspect has to be taken into consideration to establish a diagnosis. Polymerase chain reaction(PCR)of bronchial lavage fluid was examined in 13 cases, and Mycobacterium tuberculosis direct test(MTD), in 22 cases. The results of PCR showed no definite tendency. On the other hand, MTD results coincided significantly with the results of the culture of the bronchial lavage fluid, suggesting that it could provide useful information for establishing early diagnosis, differential diagnosis from non-tuberculous mycobacteriosis, and therapeutic strategy.

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[Purpose]Although the usefulness of bronchoscopy in the diagnosis of pulmonary tuberculosis has been demonstrated by many investigators, the value of bronchoscopy is not universally satisfactory. The purpose of this study was to asses the value of bronchoscopy for diagnosis of tuberculosis. [Method]A retrospective analysis was done of 80 patients suspected of having pulmonary tuberculosis but who had negative sputum smear and polymerase chain reaction(PCR)between January 1997 and March 2000. Bronchial curettage, bronchial lavage and transbronchial biopsy were performed in all patients. We investigated the diagnostic rate for tuberculosis by the combination of those procedures. [Results]Bronchial curettage detected acid-fast bacilli in 30 of the 80 cases(37.5%), PCR of bronchial lavage was positive in 41 of 80 cases(51.2%), culture in 50 of 80(62.5%), and biopsy in 50 of 80(62.5%). Chest radiographic findings were classified into two types : nodules or infiltration. The nodular type consisted 48 cases and 32 were infiltration type. The positive rates in the nodular type were as follows : curettage 27.1%, culture 52.1%, PCR 39.6%, biopsy 56.3%. The positive rates in the infiltration type were as follows : curettage 53.1%, culture 78.1%, PCR 68.8%, biopsy 71.8%. [Conclusion] The positive rate of biopsy was higher than that of curettage and PCR, and as high as that of culture. These findings suggested that bronchoscopy with transbronchial biopsy was valuable for the early diagnosis of pulmonary tuberculosis.

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The increasing use of thoracoscopy performed under local anesthesia has made contributions to the diagnosis of pleural disease with effusion. We performed 110 thoracoscopy procedures, using a flexible fiberoptic bronchoscope during the past 7 years. Among these, 15 cases of tuberculous pleurisy were diagnosed and were investigated with respect to thoracoscopic findings. Redness on the parietal pleura was seen in 9 cases(60%), multiple white nodules on the parietal pleura were seen in 10 cases(75%), a funicular membranous white thickness on the pleura was seen in 9 cases(60%) and a fibrin network was observed in 2 cases(13%). Redness on the parietal pleura and multiple white nodules on the parietal pleura were thought to be early stage cases and all biopsies were compatible with tuberculosis. Thoracoscopy appears very useful for the diagnosis of tuberculous pleurisy and helpful in the diagnosis of the stage of tuberculosis.

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To evaluate the essential points in diagnosing endobronchial tuberculosis(EBTB), we retrospectively analyzed the clinical records of 33 patients(14 men and 19 women)in whom EBTB was diagnosed between June 1992 and May 2000, including clinical course, laboratory and roentogenographic findings on admission and serial bronchoscopic findings. Most patients had symptoms such as persistent cough, sputum production or fever. The results of routine laboratory studies were within normal limits except for the blood sedimentation rate and tuberculin skin test. Sputum smear for acid-fast bacilli was positive in 63% of the patients. The findings of chest roentogenographies varied, and the cases which revealed minimal changes were not uncommon. On CT, the bronchial stenosis, obstruction, or both were observed in 19 cases. However, the distribution pattern of shadows in EBTB was clearly different from that in post-primary pulmonary tuberculosis, with 15 cases being lower lung field tuberculosis. This often led to misdiagnosis and long delay in setablishing a correct diagnosis. The locations of endobronchial lesions observed on bronchoscopy also varied. Continuous ulcerative lesions were observed in many cases, while skip lesions were observed in some cases. Lesions due to perforation by lymph nodes were observed in most of the elderly patients. In conclusion, it is important to perform microbiological examination for acid-fast bacilli to correctly diagnose EBTB which shows a different from of disease from post-primary tuberculosis. It is also important to perform bronchoscopy for cases with persistent cough of unknown origin.

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In order to assess the clinical features and courses of endobronchoal tuberculosis, involving from the trachea to segmental bronchi, we studied 48 patients who were admitted to the TB ward of International Medical Center of Japan, from 1994 to 1999. We noticed a higher incidence in females, and it was present mainly in the main bronchus. Cough was the most common complaint, in 96% of the cases. The symptomatic duration before antituberculous chemotherapy was long(on an average 4.6 months), and they were often treated as bronchial asthma or bronchitis. Bronchoscopic examination is necessary for diagnosis. The scars sometimes gave rise to severe stenosis, especially when the lesions enter into an advanced stage, or develop all around the lumen before treatment. We tried to treat with INH inhalation as well as systemic chemotherapy. However, there was no difference between local & systemic treatment and systemic treatment alone for the efficient prevention of stenosis. Five cases required surgical intervension(bronchoplasty and lobectomy)in order to avoid atelectasis or secondary infection. Early diagnosis and appropriate treatment are most important, and bronchoscopic examination is essential.

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Classification of bronchoscopic findings in bronchial tuberculosis should express the stage of the disease and its prognosis. For this purpose, the author proposed a new classification of bronchoscopic findings and analyzed its usefulness. The classification consists of five major types : Type I, edema and congestion of the mucosa ; Type II, intramucosal tubercles ; Type III, ulcer(IIIa, superficial ulcer and IIIb, granulomatous ulcer) ; Type IV, granulation (IVa, nodular granulation and IVb, polypoid granulation) ; Type V, scar(Va, scar without stenosis and Vb, scar with stenosis). In addition, the finding of perforation of tuberculous lymph node was classified as Type LN. One hundred and twelve patients with bronchial tuberculosis, 37 male and 75 female, were analyzed with this new classification. They were divided into three groups categorized according to treatment states. Group A consisted of patients before treatment, Group B consisted of patients under chemotherapy for more than one month, and Group C consisted of patients with recurrence after chemotherapy. The right side was involved in 48 cases, among which the right main bronchus was involved most frequently(in 17 cases) ; followed by the right upper lobe bronchus ; and then the right truncus intermedius as the third. The left side was involved in 64 cases, among which the left main bronchus was involved most frequently(in 47 cases, 73.4%). Analysis of bronchoscopic findings by the new classification revealed that Type III was most frequently observed in Group A(48 cases, 76%), in which Type IIIb was the commonest(34 cases). In Group A, 3 cases of Type II were present. In Group B, no case of Type II nor Type IIIa was present, and Type IIIb was observed only in a few cases. This fact indicated that Type II and Type IIIa might be easily healed by treatment. Type Vb was seen more commonly in both Group B and Group C. Type Va was not observed in any group. Changes in bronchoscopic findings by treatment were analyzed in 26 previously untreated patients, in which 30 bronchial lesions and 6 tracheal lesions were observed more than two different times before and after chemotherapy. Three lesions of Type II and nine lesions of Type IIIa healed and changed to normal finding in 11 and to Type Va in 1, during the observation period of up to 120 days. Twenty-four lesions of Type IIIb were observed and 18 of them were confirmed to be healed : 8 lesions changed to normal finding, 4 lesions to Type Va and 6 lesions to Type Vb. Duration of observation until confirmation of the healing was within 90 days in 8 lesions, within 120 days in 14, and more than 121 days in 5. Type IV was frequently observed during the treatment of Type IIIb. This fact might indicate that Type IV was one stage of the healing process of Type IIIb. In conclusion, the new classification of bronchoscopic findings in bronchial tuberculosis, which was proposed here, is useful for staging the disease and for prediction of the healing process.

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We reexamined bronchoscopic findings of active tracheobronchial tuberculosis cases according to Japanese Arai's classification : edema and congestion(type 1), intramucosal tubercle(type 2), superficial or granulomatous ulceration(type 3), nodular or polypoid granulation(type 4), scar with or without stenosis (type 5). Materials and Method : The serial bronchoscopic pictures of 53 cases of active tracheobronchial tuberculosis were reinvestigated. Result and Comment : Of the 53 cases, 7 were cavitary and 46 were noncavitary or did not show findings suggestive of pulmonary tuberculosis on their initial X-ray films. On examinations for tuberculous bacilli, 41 cases were smear positive in sputum, 6 were smear positive in materials from bronchial lavages, 4 were smear negative and culture positive, 2 were negative on both smear and culture. These cases showed various and extensive tracheobronchial abnormalities at first. The bronchoscopic findings of the most advanced involvements in individual cases were classified as follows : Arai's type 2 was seen in 4 cases, type 3 in 44(8 superficial, 36 granulomatous), type 4 in 3(1 nodular, 2 polypoid), type 5 in 2(with stenosis). In many of the 36 cases with granulomatous ulcerations marked stenoses were recognized in major airways. Continuous observations of several cases suggested that anti tuberculous chemotherapy for 2 months could convert the granulomatous ulcerations to healing scars in only 36% of cases. Our studies indicate that in active tracheobronchial tuberculosis, pulmonary lesions are relatively mild in spite of much expectoration of tuberculous bacilli, and granulomatous ulceration is the most advanced and lasting tuberculous lesion on the walls of major airways.

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This study is an analysis of clinical factors and treatment for tracheo-bronchial stenosis following tracheo-bronchial tuberculosis. The patients were classified into two groups according to whether they were treated or not. Group A was not treated specifically for stenosis and Group B was treated by endoscoic and surgical procedures. The average age of detection of tracheo-bronchial tuberculosis in Group A was fifteen years older than that in Group B. In both groups the disease was detected in two thirds of the cases due to symptoms. The lesions of tracheo-bronchial tuberculosis were detected earlier in Group A than Group B in the cours of disease. Secondary changes(atelectasis and/or obstructive pneumonia)were found in chest X-rays in 29.6% (42/142) of Group A and in 58% (36/62) of Group B. Group A was treated by anti-tuberculous chemotherapy (137/142). In Group B 10 of 60 cases received endoscopic treatment and 52 cases were treated by surgery, among which 30 underwent tracheal and bronchial reconstruction. As a result of this treatment, bronchoscopy and chest X-ray showed that an improvement of stenosis was found in 70 patients of Group A. In 15 patients there was deterioration and 12 patients showed no change. However, in 40 patients findings remain unknown without further assessment. In Group B, 5 of 10 patients of endoscopic therapy improved and 50 of 52 patients returned to regular work.

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Objective : Getting through the study of the treatment for tuberculous bronchial stricture, we looked for its acceptable strategy in the future. Subjects : 12 male and 14 female patients with bronchial tuberculosis were entered into this study. 14 patients were over 61 years of age. Four patients were operated upon soon after admission, because three of them showed tuberculous cicatricial stenosis and one showed tracheobronchial granulomatous stenosis with severe dyspnea on admission. On the contrary, 22 patients were given antituberculous drugs for 6 to 12 months, and 11 of them who had severe posttherapeutic cicatricial stricture, were also performed surgical operation or IVR, and the other 11 patients were left untreated because they showed slight stenosis and were asymptomatic. As for treatment for the bronchial stenosis of total 15 patients, bronchoplasty with or without lung resection was performed in 6 patients, lobectomy was performed in 5 patients, balloon dilation bronchoplasty(BDB) was performed in 3 patients and expandable metallic stent(EMS) was implanted in one patient. Stenotic site is bifercation and right main bronchus in one, left main bronchus in 6, intermediate trunk in one, right upper lobe bronchus in 4, left uper lobe bronchus in 2, and middle lobe bronchus in one. Patients' outcome and QOL were checked at the end of 20th century. Results : Except for one patients, who was a 66-year-old woman who received right sleeve pneumonectomy, but died due to obstructive pneumonia resulting from recurrence of tuberculous bronchial stricture 6 months after operation, all patients were discharged without any severe complication. All patients but one are surviving with good QOL. One impaired patient, a 72-year-old woman who underwent bronchoplasty of the left main bronchus did not obtain better QOL because of bronchial asthma. Eleven untreated patients also are doing well. Conclusions : Late results of surgical treatment and IVR for tuberculous bronchial stricture are excellent. As efforts to prevent severe posttherapeutic stenosis are increasing recently, we expect that less invasive treatment can be increasingly applied in the near future. However, the use of EMS for young patients is still controversial, because they seem to hold the risk of bronchial perforation and metallic fracture.

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This report describes the treatment of tuberculous bronchial stenosis in 7 patients. Sites of stenosis were the left main bronchus in 6 patients and the truncus intermedius in one. The diameter of the bronchus was about 3 mm in one patient, there was pinhole stenosis in 5 and complete obstruction in one. Treatment modalities used included surgical resection, balloon dilatation and stent implantation. Surgical resection had problems including lung volume loss due to pneumonectomy and restenosis at the anastomotic site. Balloon dilatation alon resulted in dilatation failure or early restenosis in all patients. Therfore, one patient was treated with baloon dilatation followed by Dumon stent implantation. Although the Dumon stent was removed due to formation of granulation tissue at the distal edge, the granulation regressed after removal of the stent. For such noncancerous stenosis, the Gianturco metallic stent should be avoided because it frequently causes bronchial wall damage with long-term use. In conclusion, we recommend Dumon stent implantation for the treatment of tuberculous bronchial stenosis. However, in the case of multi-drug resistant tuberculosis and severe pneumonia secondary to bronchial stenosis, surgical resection should be performed.

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We have been studying bacterial contamination for more than ten years, particularly mycobacterial contamination in bronchofiberscopes and automatic endoscope washers. The results obtained from a longterm study suggested that the source of the contaminants, might be not from the patients, but from environmental materials. In addition, the results strongly suggested that the mycobacterial contaminants were highly resistant to glutaraldehyde which has been routinely used for disinfection of the bronchofiberscopes, because mycobacterial strains were still isolated even when the concentration of glutaraldehyde was increased and the duration of the treatment with glutaraldehyde was prolonged. This glutaraldehyde resistance of the isolated mycobacteria was confirmed by in vitro experiments. Accordingly, it is essential to find out a disinfectant other than glutaraldehyde. In the course of research on this problem, we found that disinfectant-ethanol is more effective than glutaraldehyde for eliminating the contaminants ; the highly glutaraldehyde-resistant mycobacteria were completely inactivated by the treatment with undiluted ethanol within one minute, and even with 40% ethanol within 5 minutes. We are now making every effort to establish a suitable procedure for routine use, Employing ethanol for elimination of the mycobacterial contaminants in bronchofiberscopes and automatic endoscope washers.

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Mycobacterium can be detected from bronchial lavage fluid(BLF) even in patients without any sign of pulmonary tuberculosis or non-tuberculous mycobacteriosis(NTM). Among BLF samples obtained from 460 bronchoscopies performed between January 1997 and September 1998, 13 out of 238 specimens were smear-positive culture-negative(SPCN) for acid-fast bacilli on mycobacterial tests. Nine cases were diagnosed as contamination. We tried to change our method of washing the bronchoscope. First of all, we brushed the inside of the bronchoscope every time before washing it with automatic endoscope washers. The automatic endoscope washers were not used for lower gastrointestinal endoscopes and were sanitized by washing and ultrasonic washing for 2 minutes followed by soaking in 3.5% glutaraldehyde for 10 minutes. In BLF samples obtained from 299 bronchoscopies were performed between February 1999 to January 2000, 4 specimens were positive for acid-fast bacilli and 11 specimens were positive for acid-fast culture out of 198 mycobacterial tests performed. No specimens were SPCN. Four specimens turned out to be contamined by M.gordonae. Next, we further modified the santizing method by exchanging the antiseptic solution for the automatic endoscope washers just before washing the bronchoscope. In BLF samples obtained from 149 bronchoscopies were performed between February 2000 to September 2000, no specimen was positive for acid-fast bacilli and 1 specimen was positive for acid-fast culture out of 123 mycobacterial tests performed. This one positive specimen was diagnosed as NTM(M.Avium) and was not due to contamination. Automatic endoscope washers are widely used to wash and disinfect bronchoscopes. We must take steps to ensure that the automatic endoscope washers do not contaminate bronchoscopes. To avoid contamination, we reached the conclusion that we should exchange the antiseptic solution for the automatic endoscope washer immediately before washing the bronchoscope.

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