Background. Descending necrotizing mediastinitis (DNM) is a severe infection of the mediastinum that originates from neck and oral infection. The reported mortality rate is up to 20%. Due to the small number of cases, the therapeutic strategy for DNM is controversial. Objective and Methods. We herein report and evaluate the clinical characteristics of 8 cases of DNM that were surgically treated in our hospital between from 2011 to 2020. Results. There were 5 women (63%) with mean age of 76±7 (range 62-83) years. The focus of the inciting infection was neck infection in 6 patients and chest arthritis in 2. The underlying disease was diabetes mellitus in 4 patients. The mean preoperative CRP level was 32±13 (range 12.3-53.2) mg/dl. The Endo classification, identifying abscess progression, was I (upper carina) in 4 patients and IIA (anterior under carina) in 4 patients. No patients had a IIB (posterior under carina) classification. Transcervical drainage was performed in all patients, Video-assisted thoracic surgery (VATS) drainage and tracheostomy were performed in 3 patients each. Polymicrobial infection was found in 5 patients, mainly caused by Streptococcus species. All patients were discharged on mean postoperative day 47±36 (range 14-114). Three patients classified as IIA received VATS drainage without complications. Conclusion. Although DNM represents a severe and potentially lethal infection, a multidisciplinary approach with rapid and adequate drainage contributed to an earlier discharge. A VATS approach was useful for patients with invasion of the carina.
Background. Bronchoscopy is generally performed to evaluate and diagnose diseases of the lower respiratory tract. However, pharyngolaryngeal lesions may be unexpectedly detected during the insertion of the bronchoscope. In this study, we conducted a retrospective study to clarify the frequency, characteristics and trends concerning pharyngolaryngeal lesions unexpectedly detected during bronchoscopy. An approach to improve the detection of pharyngolaryngeal lesions is also presented. Method. For cases of bronchoscopy performed in our hospital over a five-year period from October 2014 to September 2019, we evaluated the medical records and analyzed the following features of cases with pharyngolaryngeal lesions: the age, sex, presence of subjective symptoms that might be associated with pharyngolaryngeal lesions, smoking history, and bronchoscopy purpose. Results. The total number of bronchoscopies was 4062, of which 40 (0.98%) included the detection of pharyngolaryngeal lesions, and the percentage with such findings increased year by year. The most common diagnosis was vocal cord polyps, followed by laryngeal cancer and vocal cord nodules. Cases with laryngeal cancer and vocal cord leukoplakia tended to be observed in older men who had a heavy smoking history. Conclusion. Especially in elderly patients with a smoking history, there is a high possibility of detecting pharyngolaryngeal lesions, even if patients are asymptomatic. Therefore, we should perform sufficient anesthesia of the oral cavity before conducting bronchoscopy and carefully observe the oral cavity and pharyngolarynx to check for undiagnosed lesions.
Background. Endobronchial chondroma is a rare tumor and its treatment is not established. Case. A 48-year-old woman visited a hospital with cough and wheezing. A chest computed tomography showed a mass in the left main bronchus and she visited our hospital. Result. We found a pedicled tumor with bronchoscopy, so we did cautery resection. The tumor was composed only of the cartilage component, no malignancy was found, and it was pathologically diagnosed as chondroma. Conclusion. There is no absolute standard in endoscopic and surgical resection selection for treatment of endobronchial chondromas. If endoscopic resection is possible, flexible bronchoscopic resection is considered to be a less invasive and highly curable treatment.
Background. Although transbronchial lung biopsy with endobronchial ultrasonography using a guide sheath (EBUS-GS) is performed for peripheral lesions, the diagnostic yield remains insufficient in cases in which the probe is positioned "adjacent to" the lesion during EBUS. We performed a pinpoint biopsy, in which the biopsy site is precisely determined, while the probe was adjacent to the lesion. Case. The patient was an 80-year-old woman with a ground-glass nodule (GGN) in the right upper lobe. Bronchoscopy with EBUS-GS was performed to diagnose the lesion. EBUS showed that the probe was adjacent to the lesion, and we decided to perform a pinpoint biopsy. ①We evaluated the direction which was obtained a closer view of the lesion, using the up/down angle of the bronchoscope (decision of the location in the short axis of the bronchus). ②We pulled the probe into the GS and determined the location where the EBUS images were getting dark, implying that the lesion was located at the edge of the GS (decision of the location in the long axis of the bronchus). We performed a biopsy in the area that we precisely determined and obtained a pathological diagnosis of lung adenocarcinoma. Conclusion. A pinpoint biopsy might enable us to improve the diagnostic yield in cases in which the probe is positioned adjacent to the lesion during EBUS.
Background. There are few case reports on primary lung cancer with endotracheal or endobronchial metastases. We report a case of primary lung adenocarcinoma with endobronchial metastasis. Case. The patient was a 63-year-old man with a previous spinal cord injury. He underwent surgery for primary lung cancer at 62 years of age. The lung cancers were a right upper lobe adenocarcinoma (pT1cN0M0 pStage IA3), and a right middle lobe adenocarcinoma (pTisN0M0 pStage 0). We performed video-assisted right upper and middle lobectomy with lymph node dissection. During treatment for an infected decubitus ulcer on admission, at 6 months after the operation, his respiratory condition deteriorated with desaturation and wheezing. Chest CT revealed right pleural effusion, superior mediastinal lymphadenopathy, and a space-occupying lesion at the left main bronchus. Bronchoscopy revealed a pedunculated polyp occupying the left main bronchus. Bronchoscopic tumor resection with electrocautery was performed. Subsequently, his symptoms showed a remarkable improvement. The excised left bronchial tumor was diagnosed as metastasis from the primary lung cancer (epidermal growth factor receptor mutation-positive/exon 19 deletion). Osimertinib was introduced as an additional treatment, after which chest CT revealed the disappearance of the pleural effusion, reduction of the superior mediastinal lymphadenopathy, and no local recurrence of the tumor in the left main bronchus. A chest CT scan performed 6 months after the introduction of medication showed no signs of relapse and no local recurrence was detected. Conclusion. Bronchial metastasis of lung cancer is relatively rare; thus, the present case is valuable.
Background. Previous studies have shown that the combination of surgical resection and reconstruction of the trachea is the preferred treatment for post-intubation tracheal stenosis. In recent years, endoscopic dilatation has proven successful in several cases for treating tracheal stenosis thanks to advances in endoscopic equipment and technology. However, the indications and long-term outcomes remain unclear. Case. A 23-year-old woman presented to an outside emergency department following a motor vehicle collision (MVC), where she was found to be minimally responsive. She underwent endotracheal intubation in the emergency department and shortly after admission with mechanical ventilation and remained intubated for 5 days following the MVC. She presented to the outside hospital on day 40 after extubation with a persistent cough and dyspnea that was initially diagnosed as bronchial asthma. Her symptoms continued despite 1 year of inhaled corticosteroid use, and the patient was referred to our hospital. Chest computed tomography (CT) revealed severe tracheal stenosis with scarring and a 2.1-cm contraction. At this time, the diagnosis of post-intubation tracheal stenosis was made. We performed emergent tracheal dilatation using a rigid bronchoscope. However, re-stenosis occurred after a few weeks. Bronchoscopic dilatation was performed 2 additional times. After the third episode of stenosis following dilatation, we performed tracheal resection and reconstruction with end-to-end anastomosis. The patient has shown no signs of re-stenosis in 30 months since surgery. Conclusion. Endoscopic dilatation can be attempted following post-intubation tracheal stenosis. However, given the risk of re-stenosis following the procedure, tracheal resection and reconstruction remain the surgical treatment of choice, especially for cases with scarring contraction.
Background. Lipoid pneumonia is relatively rare disease, characterized by the appearance of lipid-laden macrophages in the alveolar space. Case. A 53-year-old female was referred to our hospital due to deteriorating chest radiographic findings after antibiotic therapy for pneumonia. She was treated with corticosteroid therapy due to suspicion of organizing pneumonia; however, the disease condition did not improve. Bronchoscopy was performed for the diagnosis. She was diagnosed with lipoid pneumonia based on the presence of lipid-laden macrophages in the bronchoalveolar lavage fluids. It was confirmed that she was frequently choking on reflux of digestive juices during sleep. The disease condition improved by the additional administration of metoclopramide, dietary restrictions before sleep, and guidance concerning her sleeping position. Conclusion. We reported a case of lipoid pneumonia that developed after total gastrectomy. Reflux of digestive juices and pulmonary aspiration during sleep were considered the causes of the onset in this case. Bronchoscopy was useful for the diagnosis of lipoid pneumonia.
Background. While empyema with bronchial fistula often requires surgical treatment, difficult-to-manage bronchial fistula may persist even after surgical treatment. An alternative treatment option as a conservative approach in such cases is bronchial occlusion. Case. A 65-year-old man presented with chronic empyema caused by the Aspergillus spp. in the residual thoracic cavity after treatment for tuberculosis. Multiple bronchial fistulas occurred after long-term chronic inflammation. We performed open-window thoracostomy followed by bronchial occlusion using an Endobronchial Watanabe Spigot (EWS) but failed to close the bronchial fistula. Therefore, we attempted bronchial occlusion by injecting ethyl-2-cyanoacrylate (Aron Alpha A®) into the gap between the filled EWS and the bronchial wall, resulting in complete occlusion of the air leak. Conclusion. We reported the first successful case of closing a bronchial fistula using an EWS and Aron Alpha A® as a possible treatment of choice for bronchial fistulas.
Background. The incidence of opportunistic infections is increasing with the spread of immunosuppressant therapy and biologic agents. Among opportunistic infections, mucormycosis seems to be increasingly observed; however, it is still difficult to diagnose, and therapeutic options are limited. Case. A 55-year-old woman was diagnosed with SLE, and treated with mycophenolate mofetil and corticosteroids. Invasive pulmonary aspergillosis occurred during treatment for SLE; however, it improved with voriconazole. Subsequently, despite the continuation of treatment with voriconazole, chest X-ray and computed tomography newly showed multiple cavitary nodules spreading to both lungs, and she was referred to our hospital. A histological examination of pulmonary tissue obtained by transbronchial lung biopsy suggested a mucor-like structure, from which, DNA was extracted. PCR with specific primers identified a sequence with high homology with Cunninghamella species. The mucormycosis showed clinical and radiological improvement with three months of treatment with a lipid formulation of amphotericin B. Conclusion. We diagnosed pulmonary mucormycosis by transbronchial lung biopsy. Even though this mucormycosis was caused by a highly pathogenic species, therapeutic intervention immediately after the onset of mucormycosis and management of the primary disease led to a better prognosis.
Background. Pneumoconiosis is defined based on the fibroproliferative changes in the lung caused by inhalation of dust, such as polishing powder containing silica. Cases of dental technician's pneumoconiosis were described as early as 1939. Case. A 40-year-old male dental technician was referred to us because of nodular infiltrates on a chest radiograph. He complained of having a dry cough. He had been working as a dental technician for the past 15 years and had been engaged in polishing dental metals. Computed tomography revealed centrilobular nodules, predominantly in the upper lung fields. We performed bronchoalveolar lavage and a transbronchial lung biopsy of the right upper lobe. Biopsy specimens showed dense fibrosis with pigmented macrophages. Under a polarizing microscope, refractile materials of various sizes were observed, suggesting that minerals were present in the affected lung tissues. We performed a microanalysis of minerals in the affected lung tissue and bronchoalveolar lavage fluids using an energy-dispersive X-ray analytical spectrometer. In addition, five raw materials used in his dental laboratory were similarly analyzed. A mineral analysis revealed that the affected lung tissues and bronchoalveolar lavage fluids contained metals such as aluminum, silicon, chromium, and cobalt, which were consistent with the dental materials that the patient had handled in the laboratory. Conclusion. We diagnosed this patient with pneumoconiosis caused by inhalation of dental metals. This is the first reported case of pneumoconiosis in a dental technician wherein the metallic particles in the lung were matched with the inhaled dental materials present in the dental laboratory.
Background. Large cell neuroendocrine carcinoma arising from a bronchus is rare. Case. A 68-year-old man presented to our institution complaining of sudden dyspnea. A clinical examination revealed a mass occluding the left main bronchus. His history included right nephroureterectomy for papillary urothelial carcinoma of the right renal pelvis that had been performed 1 year previously. At the present admission, a clinical examination suggested a mass occluding the left main bronchus. Chest computed tomography confirmed the mass occluding the left main bronchus and showed enlargement of the subtracheal and right axillary lymph nodes. Bronchoscopy showed a tumor, extending from the bifurcation, which occluded the left main bronchus. Metastasis from the prior renal pelvic cancer was suspected. Because the present tumor bled easily, there was a risk of lung aspiration and airway obstruction, which precluded biopsy evaluation. The tumor was pedunculated, and was therefore endoscopically resected using an electrosurgical snare followed by placement of a Dumont Y stent. The pathological diagnosis was large cell neuroendocrine carcinoma in the left main bronchus, which was considered to be the primary lesion. Chemotherapy (carboplatin and irinotecan hydrochloride) was administered. At the 14-months follow-up examination, the tumor was controlled, with no increase in growth. Conclusion. Large cell neuroendocrine carcinoma arising from a bronchus is rare. We reported a case that was treated with endoscopic tumor resection and stent placement followed by postoperative chemotherapy.
Background. Patients with allergic bronchopulmonary mycosis can develop cystic changes and fibrosis; thus, an early diagnosis and treatment with corticosteroids and anti-fungal drugs are recommended. Case. A 73-year-old man underwent bronchoscopy because the shadow around the mucus plug of left lower lobe had expanded. The mucus plug found in the left B* (subsuperior bronchus) was removed by bronchoscopic suctioning. Although the causative agent could not be identified, Grocott's staining revealed fragment-like fungal hyphae, and the patient was diagnosed with allergic bronchopulmonary mycosis. He was followed up without medication because his symptoms improved after bronchoscopy. He had no relapse and chest CT showed the disappearance of the mucus plug. Conclusion. Although caution is required to avoid the progression of respiratory failure, in some cases, follow-up is possible without the administration of systemic steroids or anti-fungal drugs after the removal of the mucus plug.
Background. Biliopleural fistula is a rare complication of percutaneous transhepatic biliary drainage (PTBD). Although thoracic drainage, surgical curettage, and fistula closure have been reported as treatments, to our knowledge, there have been very few reports on thoracoscopy under local anesthesia. Case. An 89-year-old man had undergone biliary stent replacement for obstructive jaundice due to a duodenal papilla tumor and was hospitalized for acute cholecystitis and cholangitis by biliary stent obstruction. Three days after PTBD, he developed a fever, and chest X-ray revealed extensive right pleural effusion. Chest computed tomography confirmed that the PTBD catheter had penetrated the chest cavity. Experimental pleurocentesis revealed bile-like pleural effusion, and Enterococcus faecium and Pseudomonas aeruginosa were detected in a culture test. Empyema due to a bilopleural fistula was diagnosed. The right chest cavity formed by the intrathoracic fibrin was curetted by thoracoscopy (LTF-240) under local anesthesia, and two chest drains were inserted. The empyema and cholangitis showed improving trends following thoracic draining and treatment with antibiotics. Later, the PTBD catheter was removed, and right diaphragm fistula closure was performed using thoracoscopy under local anesthesia. Conclusion. Thoracoscopy under local anesthesia can be useful for managing empyema due to biliary thoracic fistulas. It may be particularly useful for patients with a poor performance status due to age or carcinoma who are unable to undergo highly invasive surgical procedures under general anesthesia.
Background. Surgical resection or endoscopic treatment may be considered in cases of respiratory failure due to bronchial obstruction caused by a benign tumor. Case. A 73-year-old man visited the hospital with a complaint of dyspnea on exertion. Chest radiography showed atelectasis in the left upper lobe, and computed tomography (CT) of the chest revealed a mass located mainly in the left upper lobe bronchus that extended to the lower lobe bronchial root. Bronchoscopy revealed a superficial smooth mass in the left upper lobe of the bronchus and at the entrance of the lower lobe; the biopsy results revealed a pleomorphic adenoma. Subsequently, the left lower lobe showed a reduction in air content, and respiratory failure occurred. The patient did not wish to undergo surgical treatment and was treated with endoscopy. Argon plasma coagulation (APC) and a hot biopsy were performed four times under bronchoscopy, which resulted in the opening of the lower lobe bronchi and improvement in the respiratory status. Conclusion. Endoscopic treatment with APC and a hot biopsy can be effective in cases of respiratory failure due to endobronchial pleomorphic adenoma.
Background. Immune-related adverse events (irAEs) may relapse after remission in patients who are treated with immune checkpoint inhibitors. Case. A 70-year-old man received chemotherapy and radiation therapy due to lung metastasis that appeared 4 months after surgical resection of right renal pelvis cancer. Three years later, a new lung metastatic lesion appeared, and chemotherapy was started using Pembrolizumab. However, drug-induced pneumonia developed following six sequential courses of Pembrolizumab. Pembrolizumab was withdrawn, and the pneumonia disappeared without treatment. Two months later, 23-valent pneumococcal polysaccharide vaccine (PPSV23) was given according to the national routine vaccination program. The patient developed a fever two days after the vaccination, and new lung infiltration was detected. He was admitted, and his fever was sustained. Bronchoscopy performed on day 7 after admission revealed increased leukocytes, including neutrophils, lymphocytes, and eosinophils in the alveolar space, as well as lung fibroses, findings consistent with drug-induced pneumonia. Steroid treatment led to the improvement of pneumonia. Conclusion. PPSV23 may cause the relapse of irAEs, and we should carefully consider vaccinations in patients receiving immunotherapy.