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Airway Obstruction by Anterior Mediastinal Mass
selected reports Airway Obstruction by Anterior Mediastinal Mass*
Successful Management by Percutaneous Aspiration
Stephen Flaherty, M.D.; and Brent A. Grishkin, M.D., F.C.C.P. An anterior mediastinal mass producing extrinsic airway obstruction was successfully managed by percutaneous needle aspiration, decompressing the mass and relieving the airway obstruction. This allowed safe induction of general endotracheal anesthesia and excision of the mass by a sternotomy approach.
(Chest 1994; 106:947-48) Airway obstruction from extrinsic tracheobronchial compression by a large anterior mediastinal mass has been frequently described in children 1-3 but noted less often in adults. Recommendations for treatment of such patients has included biopsy under local anesthesia, 1•2 preliminary radiation therapy without tissue diagnosis, 1•4 intubation with cardiopulmonary bypass standby, 1•2 or the use of cardiopulmonary bypass to assure cardiorespiratory stability during either intubation or the entire operative procedure. W e recently treated a young adult with a large undiagnosed anterior mediastinal mass producing airway compression, and we were able to provide for safe intubation and operation by preoperative needle aspiration of the cystic component of the mass.
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CASE REPORT
A 19-year-old, 63-kg man developed symptoms of an upper respiratory tract illness, associated with fever and mild leukocytosis. Chest radiograph (Fig 1) and computed tomogram (CT) (Fig 2) showed a large anterior mediastinal mass with cystic component suggested by CT density. Preoperative assessment included pulmonary function testing; however, adequate flow-volum e loops could not be obtained as the patient would become markedly dyspneic when in a supine position. Physical examination revealed neither lymphadenopathy nor organomegaly, but the right intercostal spaces bulged anteriorly. We planned to excise the mass via median sternotomy, with cardiopulmonary bypass standby, but believed that the cystic nature might permit percutaneous needle decompression of the mass. In the operating room, the patient's head and back were elevated to 30°. Then, under local anesthesia, needle aspiration in the right second intercostal space parasternally, with an 18-gauge needle, evacuated 1,000 ml of brown serous fluid . As the *From the Thoracic Surgery Service, Eisenhower Army Medical Center, Ft. Gordon, Ga. The opinions or assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense. Reprint requests: Dr. Grishkin, 2100 Central Avenue, Suite 5, Augusta, GA 30904
FIGURE l. Chest radiograph showing large mass extending into right side of chest. fluid was evacuated, the patient noted an improvement in his dyspnea, and h e subsequently tolerated being lowered to the supine position. His ability to now breathe comfortably while supine was adeq uate clinical evidence for relief of airway compression, allowing endotracheal intubation and induction of general anesthesia without adjunctive measures. A median sternotomy was performed and the mediastinal mass was excised. The capsule had been adjacent to the anterior chest wall, but not adherent, and had collapsed away from the parietal pleura after needle decompression of the mass, and the needle track through the intercostal muscles was identified. The mass involved the thymus and had obliterated the brachiocephalic vein (innominate vein) with thrombosis of the vein from the left internal jugular to its superior vena cava junction, but there was neither gross nor microscopic invasion of the surrounding tissues.
FIGURE 2. Computed tomogram of anterior mediastinal mass compressing mediastinal contents posteriorly, with CT density suggesting cystic component. CHEST / 106 / 3 / SEPTEMBER, 1994
947
Histopathologic diagnosis was a germ cell tumor with mature elements consistent with teratoma. The patient had an uncomplicated postoperative course, although he developed varicella 4 days postoperatively. Follow-up chest radiograph was unremarkable. DISCUSSION
Patients with large anterior mediastinal masses may experience airway obstruction because of extrinsic tracheobronchial compression , with airway collapse after induction of general anesthesia. Suggested management has included awake intubation, but a large tumor may compress the tracheobronchial tree distal to the tip of the endotracheal tube. Cardiopulmonary bypass has been suggested to allow cardiorespiratory stability during intubation, anesthesia induction, or for the duration of the operation to take a biopsy specimen or resect the mass. Needle aspiration biopsy of a solid mass using local anesthesia may provide a tissue diagnosis, allowing radiation or chemotherapy to reduce the size of the mass. If a mediastinal mass appears to have a large cystic component, needle aspiration may relieve airway compression. Intraoperative bronchoscopic transcarinal aspiration of a subcarinal bronchogenic cyst has been used to relieve airway obstruction that occurred after induction of general anesthesias Preoperative CT of a mediastinal mass may show low density, suggesting a serous cystic component. However, blood or other proteinaceous cyst contents may produce higher CT density, obscuring the cystic component. These cysts with complex contents may be identified using magnetic resonance imaging producing high signal intensity on both Tl- and T2- weighted images, in contrast to the low Tl and bright T2 signals from serous cysts.6 If an anterior mediastinal mass has a large cystic component demonstrated by CT or magnetic resonance imaging, and clinical evidence of airway compression, percutaneous needle aspiration, as in this case, may provide adequate decompression to afford safe induction of general anesthesia and the performance of a definitive surgical procedure.
REFERENCES
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3 4 5
6
Azizkhan RG, Dudgeon DL, Buck JR, Colombani DL, Yaster M, Nichols D, et a!. Life threatening airway obstruction as a complication to the management of mediastinal masses in children. J Pediatr Surg 1985; 20:816-22 Neuman GG, Weingarten AE, Abramowitz RM, Kushins LG, Abramson AL, Ladner W. The anesthetic management of the patient with an anterior mediastinal mass. Anesthesiology 1984; 60:144-47 Pullerits J, Holzmon R. Anesthesia for patients with mediastinal masses. Can J Anaesth 1989; 36:681-88 Greengrass R. Anesthesia and mediastinal masses. Can J Anaesth 1990; 37:596 McDougall JC, Fromme G. Transcarinal aspiration of a mediastinal cyst to facilitate anesthetic management. Chest 1990; 97:1490-92 Suen H-C, Mathisen DJ, Grillo HC, LeBlanc J, McLoud TC, Moncure AC, et al. Surgical management and radiological characteristiCs of bronchogenic cysts. Ann Thorac Surg 1993; 55:476-81
948
Pulmonary Sequestration Receiving Arterial Supply From the Left Circumflex Coronary Artery* Michael E. Silverman, M.D.; Charles S. White , M.D .; and Andrew A. Ziskind, M.D.
Pulmonary sequestration is an uncommon anomaly for which the arterial supply is usually derived from the aorta or its major branches. A 66-year-old man is described with a pulmonary sequestration that received its arterial supply from a coronary artery. (Chest 1994; 106:948-49)
P
ulmonary sequestration is an uncom~on. congenital anomaly in which masses of nonfunctwnmg pulmonary parenchyma do not communicate with the tracheobronchial tree through a normally located bronchus.1 Traditionally , sequestrations are divided into two types, intralobar and extralobar, with two thirds occurring in the left lower lobe and one third occurring in the right lower lobe. Their arterial supply most frequently originates from the thoracic or abdominal aorta, but other origins of arterial supply have been described. We report the first case (to our knowledge) of a pulmonary sequestration diagnosed as an incidental finding at cardiac catheterization by virtue of its blood supply arising from the left circumflex coronary artery. CASE REPORT
A 66-year-old man with known coronary artery disease developed progressive angina, unresponsive to medical therapy. His history was notable for an episode of severe pneumonia at age 9 years. Results of the physical examination were unremarkable, as were laboratory studies. The electrocardiogram revealed normal sinus rhythm with nonspecific ST segment changes. The chest radiograph suggested a density in the left lower lobe with a cystic component. Cardiac catheterization was performed to assess the extent of coronary artery disease. It showed moderate to severe disease of the left anterior descending and right coronaries. The left circumflex was free of coronary disease; however, its left atrial branch gave rise to a large anomalous vessel that supplied a vascular left posterior lung mass. Venous drainage from the mass flowed into pulmonary vasculature (Fig 1). Computed tomography demonstrated an opacity in the left lower lobe that contained multiple cysts with air fluid levels (Fig 2). There was associated volume loss with mediastinal shift to the left. An aortogram revealed no aorta-derived blood supply to the pulmonary sequestration.
*From the Division of Cardiology, Department of Medi~ine (J:?rs. Silverman and Ziskind) and Department of D1agnoshc Radwlogy (Dr. White), University of Maryland, B.a ltimore. . Reprint requests: Dr. Ziskind, Director, Cardwc Cath Lab, Umversity of Maryland Medical Center, Division of Cardwlogy, N3W77, 22 S. Greene Street, Baltimore 21201 Pulmonary Sequestration (Silverman, White, Ziskind)
Successful Management by Percutaneous Aspiration
Stephen Flaherty, M.D.; and Brent A. Grishkin, M.D., F.C.C.P. An anterior mediastinal mass producing extrinsic airway obstruction was successfully managed by percutaneous needle aspiration, decompressing the mass and relieving the airway obstruction. This allowed safe induction of general endotracheal anesthesia and excision of the mass by a sternotomy approach.
(Chest 1994; 106:947-48) Airway obstruction from extrinsic tracheobronchial compression by a large anterior mediastinal mass has been frequently described in children 1-3 but noted less often in adults. Recommendations for treatment of such patients has included biopsy under local anesthesia, 1•2 preliminary radiation therapy without tissue diagnosis, 1•4 intubation with cardiopulmonary bypass standby, 1•2 or the use of cardiopulmonary bypass to assure cardiorespiratory stability during either intubation or the entire operative procedure. W e recently treated a young adult with a large undiagnosed anterior mediastinal mass producing airway compression, and we were able to provide for safe intubation and operation by preoperative needle aspiration of the cystic component of the mass.
ft
CASE REPORT
A 19-year-old, 63-kg man developed symptoms of an upper respiratory tract illness, associated with fever and mild leukocytosis. Chest radiograph (Fig 1) and computed tomogram (CT) (Fig 2) showed a large anterior mediastinal mass with cystic component suggested by CT density. Preoperative assessment included pulmonary function testing; however, adequate flow-volum e loops could not be obtained as the patient would become markedly dyspneic when in a supine position. Physical examination revealed neither lymphadenopathy nor organomegaly, but the right intercostal spaces bulged anteriorly. We planned to excise the mass via median sternotomy, with cardiopulmonary bypass standby, but believed that the cystic nature might permit percutaneous needle decompression of the mass. In the operating room, the patient's head and back were elevated to 30°. Then, under local anesthesia, needle aspiration in the right second intercostal space parasternally, with an 18-gauge needle, evacuated 1,000 ml of brown serous fluid . As the *From the Thoracic Surgery Service, Eisenhower Army Medical Center, Ft. Gordon, Ga. The opinions or assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense. Reprint requests: Dr. Grishkin, 2100 Central Avenue, Suite 5, Augusta, GA 30904
FIGURE l. Chest radiograph showing large mass extending into right side of chest. fluid was evacuated, the patient noted an improvement in his dyspnea, and h e subsequently tolerated being lowered to the supine position. His ability to now breathe comfortably while supine was adeq uate clinical evidence for relief of airway compression, allowing endotracheal intubation and induction of general anesthesia without adjunctive measures. A median sternotomy was performed and the mediastinal mass was excised. The capsule had been adjacent to the anterior chest wall, but not adherent, and had collapsed away from the parietal pleura after needle decompression of the mass, and the needle track through the intercostal muscles was identified. The mass involved the thymus and had obliterated the brachiocephalic vein (innominate vein) with thrombosis of the vein from the left internal jugular to its superior vena cava junction, but there was neither gross nor microscopic invasion of the surrounding tissues.
FIGURE 2. Computed tomogram of anterior mediastinal mass compressing mediastinal contents posteriorly, with CT density suggesting cystic component. CHEST / 106 / 3 / SEPTEMBER, 1994
947
Histopathologic diagnosis was a germ cell tumor with mature elements consistent with teratoma. The patient had an uncomplicated postoperative course, although he developed varicella 4 days postoperatively. Follow-up chest radiograph was unremarkable. DISCUSSION
Patients with large anterior mediastinal masses may experience airway obstruction because of extrinsic tracheobronchial compression , with airway collapse after induction of general anesthesia. Suggested management has included awake intubation, but a large tumor may compress the tracheobronchial tree distal to the tip of the endotracheal tube. Cardiopulmonary bypass has been suggested to allow cardiorespiratory stability during intubation, anesthesia induction, or for the duration of the operation to take a biopsy specimen or resect the mass. Needle aspiration biopsy of a solid mass using local anesthesia may provide a tissue diagnosis, allowing radiation or chemotherapy to reduce the size of the mass. If a mediastinal mass appears to have a large cystic component, needle aspiration may relieve airway compression. Intraoperative bronchoscopic transcarinal aspiration of a subcarinal bronchogenic cyst has been used to relieve airway obstruction that occurred after induction of general anesthesias Preoperative CT of a mediastinal mass may show low density, suggesting a serous cystic component. However, blood or other proteinaceous cyst contents may produce higher CT density, obscuring the cystic component. These cysts with complex contents may be identified using magnetic resonance imaging producing high signal intensity on both Tl- and T2- weighted images, in contrast to the low Tl and bright T2 signals from serous cysts.6 If an anterior mediastinal mass has a large cystic component demonstrated by CT or magnetic resonance imaging, and clinical evidence of airway compression, percutaneous needle aspiration, as in this case, may provide adequate decompression to afford safe induction of general anesthesia and the performance of a definitive surgical procedure.
REFERENCES
2
3 4 5
6
Azizkhan RG, Dudgeon DL, Buck JR, Colombani DL, Yaster M, Nichols D, et a!. Life threatening airway obstruction as a complication to the management of mediastinal masses in children. J Pediatr Surg 1985; 20:816-22 Neuman GG, Weingarten AE, Abramowitz RM, Kushins LG, Abramson AL, Ladner W. The anesthetic management of the patient with an anterior mediastinal mass. Anesthesiology 1984; 60:144-47 Pullerits J, Holzmon R. Anesthesia for patients with mediastinal masses. Can J Anaesth 1989; 36:681-88 Greengrass R. Anesthesia and mediastinal masses. Can J Anaesth 1990; 37:596 McDougall JC, Fromme G. Transcarinal aspiration of a mediastinal cyst to facilitate anesthetic management. Chest 1990; 97:1490-92 Suen H-C, Mathisen DJ, Grillo HC, LeBlanc J, McLoud TC, Moncure AC, et al. Surgical management and radiological characteristiCs of bronchogenic cysts. Ann Thorac Surg 1993; 55:476-81
948
Pulmonary Sequestration Receiving Arterial Supply From the Left Circumflex Coronary Artery* Michael E. Silverman, M.D.; Charles S. White , M.D .; and Andrew A. Ziskind, M.D.
Pulmonary sequestration is an uncommon anomaly for which the arterial supply is usually derived from the aorta or its major branches. A 66-year-old man is described with a pulmonary sequestration that received its arterial supply from a coronary artery. (Chest 1994; 106:948-49)
P
ulmonary sequestration is an uncom~on. congenital anomaly in which masses of nonfunctwnmg pulmonary parenchyma do not communicate with the tracheobronchial tree through a normally located bronchus.1 Traditionally , sequestrations are divided into two types, intralobar and extralobar, with two thirds occurring in the left lower lobe and one third occurring in the right lower lobe. Their arterial supply most frequently originates from the thoracic or abdominal aorta, but other origins of arterial supply have been described. We report the first case (to our knowledge) of a pulmonary sequestration diagnosed as an incidental finding at cardiac catheterization by virtue of its blood supply arising from the left circumflex coronary artery. CASE REPORT
A 66-year-old man with known coronary artery disease developed progressive angina, unresponsive to medical therapy. His history was notable for an episode of severe pneumonia at age 9 years. Results of the physical examination were unremarkable, as were laboratory studies. The electrocardiogram revealed normal sinus rhythm with nonspecific ST segment changes. The chest radiograph suggested a density in the left lower lobe with a cystic component. Cardiac catheterization was performed to assess the extent of coronary artery disease. It showed moderate to severe disease of the left anterior descending and right coronaries. The left circumflex was free of coronary disease; however, its left atrial branch gave rise to a large anomalous vessel that supplied a vascular left posterior lung mass. Venous drainage from the mass flowed into pulmonary vasculature (Fig 1). Computed tomography demonstrated an opacity in the left lower lobe that contained multiple cysts with air fluid levels (Fig 2). There was associated volume loss with mediastinal shift to the left. An aortogram revealed no aorta-derived blood supply to the pulmonary sequestration.
*From the Division of Cardiology, Department of Medi~ine (J:?rs. Silverman and Ziskind) and Department of D1agnoshc Radwlogy (Dr. White), University of Maryland, B.a ltimore. . Reprint requests: Dr. Ziskind, Director, Cardwc Cath Lab, Umversity of Maryland Medical Center, Division of Cardwlogy, N3W77, 22 S. Greene Street, Baltimore 21201 Pulmonary Sequestration (Silverman, White, Ziskind)