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Broncholith Removal Using Cryotherapy During Flexible Bronchoscopy
6 Shyu MY, Lee AY, Lee BJ, et al. Right atrial and ventricular thrombi after blunt chest trauma. J Trauma 2002; 52:765–766 7 Hung MJ, Wang CH, Cherng WJ. Left ventricular thrombus after seat-belt-related chest trauma. J Trauma 1999; 47:599 – 601 8 Mahy IR, Al-Mohammad A, Cargill RI. Left atrial thrombus as an early consequence of blunt chest trauma. Heart 1998; 79:198 –199 9 Ruvolo G, Fattouch K, Speziale G, et al. Left ventricular thrombosis after blunt chest trauma. J Cardiovasc Surg (Torino) 2001; 42:211–212 10 Chaowalit N, Dearani JA, Edwards WD, et al. Calcified right ventricular mass and pulmonary embolism in a previously healthy young woman. J Am Soc Echocardiogr 2005; 18:275– 277 11 Rechavia E, Imbar S, Birnbaum Y, et al. Protruding left ventricular thrombus formation following blunt chest trauma. Am Heart J 1993; 125:893– 896 12 Fabian TC, Mangiante EC, Patterson CR, et al. Myocardial contusion in blunt trauma: clinical characteristics, means of diagnosis, and implications for patient management. J Trauma 1988; 28:50 –57 13 Hiatt JR, Yeatman LA Jr, Child JS. The value of echocardiography in blunt chest trauma. J Trauma 1988; 28:914 –922 14 Chirillo F, Totis O, Cavarzerani A, et al. Usefulness of transthoracic and transoesophageal echocardiography in recognition and management of cardiovascular injuries after blunt chest trauma. Heart 1996; 75:301–306 15 Chung B, Wong V. Pediatric stroke among Hong Kong Chinese subjects. Pediatrics 2004; 114:206 –212 16 Lynch JK, Hirtz DG, DeVeber G, et al. Report of the National Institute of Neurological Disorders and Stroke workshop on perinatal and childhood stroke. Pediatrics 2002; 109:116 –123 17 Biffl WL, Moore FA, Moore EE, et al. Cardiac enzymes are irrelevant in the patient with suspected myocardial contusion. Am J Surg 1994; 168:523–527 18 Jackson L, Stewart A. Best evidence topic report: use of troponin for the diagnosis of myocardial contusion after blunt chest trauma. Emerg Med J 2005; 22:193–195 19 Bertinchant JP, Polge A, Mohty D, et al. Evaluation of incidence, clinical significance, and prognostic value of circulating cardiac troponin I and T elevation in hemodynamically stable patients with suspected myocardial contusion after blunt chest trauma. J Trauma 2000; 48:924 –931 20 Velmahos GC, Karaiskakis M, Salim A, et al. Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. J Trauma 2003; 54:45–50
Broncholith Removal Using Cryotherapy During Flexible Bronchoscopy* A Case Report Anita J. Reddy, MD; Joseph A. Govert, MD; Thomas A. Sporn, MD; and Momen M. Wahidi, MD Pulmonary broncholithiasis can cause a management dilemma depending on its location and the possible involvement of vascular structures. Many patients www.chestjournal.org
undergo rigid bronchoscopy or surgical interventions for the removal of broncholiths. In this case report, we describe a 38-year-old white man with a history of performing warehouse demolitions who presented with chronic cough, dyspnea on exertion, and recurrent pneumonia. Imaging studies revealed hilar and mediastinal calcifications, as well as a calcification in the right middle lobe bronchus. Flexible bronchoscopy revealed a mobile obstructing calcified mass in the right middle lobe bronchus. Attempts at removing the mass with forceps were unsuccessful. Instead, the mass was removed using cryotherapy with minimal bleeding and complete resolution of the obstruction. Pathologic examination confirmed that the mass was a broncholith, and stains revealed the presence of histoplasma fungal forms. Partially attached broncholiths can be removed safely using flexible bronchoscopy with the aid of cryotherapy. (CHEST 2007; 132:1661–1663) Key words: broncholith; bronchoscopy; cryotherapy
male construction worker was referred to A our38-year-old institution for recurrent pneumonias and right
middle lobe obstruction. He had spent most of his life in Texas employed in construction and sheet metal fabrication, but he had spent a year in the Lexington, KY, area performing demolition work. Seven months prior to presentation at our institution, the patient reported symptoms of persistent dry cough, which then progressed to a cough productive of purulent sputum and dyspnea on exertion. He was treated with antibacterial therapy for right middle lobe pneumonia. Follow-up chest radiographs revealed persistent right middle lobe infiltrates; therefore, a chest CT scan was performed, revealing multiple calcified hilar and mediastinal lymph nodes, as well as obstruction of the right middle lobe bronchus in association with an area of calcification. Bronchoscopy was performed at the referring institution and revealed an obstruction of the right middle orifice by a mass that could not be removed. Endobronchial biopsies were performed, and pathology findings revealed significant calcium deposits. Symptoms of fever and productive cough again developed in the patient, and, due to his recurrent symptoms,
*From the Department of Medicine (Drs. Reddy, Govert, and Wahidi), Division of Pulmonary, Allergy and Critical Care Medicine, and the Department of Pathology (Dr. Sporn), Duke University Medical Center, Durham, NC. The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Manuscript received March 22, 2007; revision accepted April 18, 2007. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Anita J. Reddy, MD, Associate Staff, Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic Health System, 9500 Euclid Ave, Desk A90, Cleveland, OH 44195; e-mail: [email protected] DOI: 10.1378/chest.07-0739 CHEST / 132 / 5 / NOVEMBER, 2007
1661
he was referred to our institution for further evaluation. At the time of presentation to our clinic, he reported mild dry cough without hemoptysis and mild dyspnea on exertion. The findings of the physical examination were normal with normal oxygen saturation while breathing room air. A lung examination did not reveal any bronchial breath sounds, crackles, or wheezes. A chest CT scan (Fig 1) revealed marked calcification of hilar lymph nodes and the subcarinal lymph node, and an area of dense calcification obstructing the right middle lobe bronchus leading to near-complete collapse of the medial and lateral segments of the right middle lobe. Calcifications were also noted in the spleen. Repeat bronchoscopy at our institution revealed complete obstruction of the right middle lobe bronchus by a calcified mass, which was partially mobile within the bronchus (Fig 2). Attempts at removing the mass using forceps were unsuccessful. Cryotherapy was then employed as a means of removal. This resulted in near-complete removal of the mass with resolution of the obstruction, although a small remnant stalk continued to be present within the lateral wall of the right middle lobe bronchus. Coagulation of the stalk was not performed prior to cryotherapy since the stalk was not fully visualized prior to broncholith removal. Minimal bleeding was encountered after removal. Pathologic examination revealed fragments of chronically inflamed bronchial tissue with fibrocalcific debris consistent with a broncholith (Fig 3). Histochemical stains were positive for yeast, with morphology typical of Histoplasma capsulatum. This patient will be followed up for the recurrence of respiratory symptoms. If his cough should return, a follow-up bronchoscopy would be performed to detect the recurrence of broncholithiasis. A chest CT scan would also be considered to evaluate for associated complications of histoplasmosis such as granulomatous mediastinitis or progressive mediastinal fibrosis. Histoplasma is commonly cultured from calcified lymph nodes and broncholiths in asymptomatic patients, and no antimicrobial treatment is
Figure 2. Top, A: a bronchoscopic view showing the partially attached broncholith in the right middle lobe bronchus. Center, B: remnant stalk within the right middle lobe bronchus after removal of a broncholith. Bottom, C: extracted broncholith.
recommended unless evidence of chronic histoplasmosis or other complications such as granulomatous mediastinitis develops in the patient.1
Discussion
Figure 1. CT scan image (lung window) showing calcifications present within the right middle lobe bronchus and right hilar lymph nodes. 1662
Broncholithiasis is a rare disorder that is marked by hilar and/or parenchymal calcifications in response to an inflammatory process. Pulmonary tuberculosis is the most common cause of broncholithiasis worldwide, while histoplasmosis is the most common cause in the United States. Other causes include cryptococcus, coccidioidomycosis, actinomycosis, aspergillosis, nocardiosis, silicosis, and malignancy. Patients with broncholithiasis can present with a variety of symptoms. The most common symptoms include persistent cough, hemoptysis, recurrent pneumonia, wheezing, and dyspnea. Lithoptysis, or expectoration of small stones, is a rare but pathognomonic sign Selected Reports
Figure 3. Top, A: bronchial tissue with fibrocalcific and necrotic debris (following decalcification) [hematoxylin-eosin, original magnification ⫻100]. Bottom, B: yeast with morphology typical of H capsulatum (methenamine-silver, original magnification ⫻400).
of broncholithiasis. Broncholithiasis can result in a number of complications, including erosion of broncholiths into the bronchial wall, resulting in airway obstruction and/or hemoptysis, as well as erosion into the esophagus or vasculature. Chest radiographs can reveal calcification of the hilar and mediastinal lymph nodes, parenchymal calcification, or obstruction of the airways leading to atelectasis, mucoid impaction, bronchiectasis, or airtrapping. Other manifestations include migration or disappearance of a calcific focus. The management of broncholithiasis is dependent on the degree of symptoms as well as the size and location of the broncholiths. Possible interventions include flexible bronchoscopy, rigid bronchoscopy, and surgical management. Utilizing bronchoscopy for the removal of broncholiths can be difficult due to the embedding of the stone into surrounding structures, large size, and difficulty crushing the stone. Flexible bronchoscopy can be used to establish a diagnosis, as well as for the removal of broncholiths. Success rates using flexible bronchoscopy for the removal of broncholiths is reported to be approximately 30%, and there have been reports2– 4 utilizing balloon catheters and tripod forceps with success, especially in cases where a loose broncholith is present. Complications can include hemoptysis and central airway obstruction due to a loose stone. Rigid bronchoscopy is also employed for the removal of broncholiths with success rates ranging from 67 to 87%.5 Several institutions have described the use of Nd-YAG and holmium-YAG lasers to fragment large endobronchial stones.3,5 Complications associated with lasers include perforation of the bronchial wall and hemorrhage. www.chestjournal.org
A key question in the management of broncholiths is whether to attempt bronchoscopic removal or to proceed with surgical resection. One large retrospective series by Olsen et al4 identified the degree of attachment of the broncholith to the bronchial wall as a factor in the success rate of bronchoscopic removal. Bronchoscopic excision was successful in 48% of patients with partially eroding broncholiths and in 100% of those with loose broncholiths. Surgical treatment should be considered over bronchoscopic removal when patients present with hemoptysis, the broncholith is firmly attached to the bronchial wall, or bronchoscopic excision is not available or feasible. Preferred operative procedures include segmentectomy, followed by lobectomy and pneumonectomy.6,7 Complications include laceration of the pulmonary artery, esophageal perforation, and mainstem bronchus tear. In this case, we describe the first report of using cryotherapy during flexible bronchoscopy for the removal of a broncholith. Cryotherapy has been used for the removal of foreign objects, blood clots, granulation tissue, and mucous plugs,8 as well as the management of endobronchial obstruction.9 The advantages of cryotherapy include ease of use, lower cost compared to laser therapies, and reusability of the cryoprobe after disinfection. Complications can include bleeding or airway perforation, especially when intervention includes manipulation of the broncholith stalk. Caution should also be taken when using cryotherapy for this indication and should only be performed by experienced pulmonologists who have been trained in interventional bronchoscopy until further experience is gained and safety is established. Our experience in this patient indicates that cryotherapy can be an alternative treatment option in the removal of mobile or partially attached broncholiths with flexible bronchoscopy. This modality can be particularly useful when broncholiths are not easily amenable to removal with forceps extraction during flexible bronchoscopy.
References 1 Kauffman CA. Histoplasmosis: a clinical and laboratory update. Clin Micr Rev 2007, 20:115–132 2 Yi K, Lee H, Park S, et al. Two cases of broncholith removal under the guidance of flexible bronchoscopy. Korean J Intern Med 2005; 20:90 –91 3 Menivale F, Deslee G, Vallerand H, et al. Therapeutic management of broncholithiasis. Ann Thorac Surg 2005; 79:1774 –1776 4 Olson EJ, Utz JP, Prakash UB. Therapeutic bronchoscopy in broncholithiasis. Am J Respir Crit Care Med 1999; 160:766 –770 5 Ferguson JS, Rippentrop JM, Fallon B, et al. Management of obstructing pulmonary broncholithiasis with threedimensional imaging and holmium laser lithotripsy. Chest 2006; 130:909 –912 6 Faber L, Jensik R, Chawla S, et al. The surgical implication of broncholithiasis. J Thorac Cardiovasc Surg 1975; 70:779 –789 7 Potaris K, Miller DL, Trastek VF, et al. Role of surgical resection in broncholithiasis. Ann Thorac Surg 2000; 70:248 –251 8 Wahidi MM, Herth FJF, Ernst A. State of the art: interventional pulmonology. Chest 2007; 131:261–274 9 Mathur PN, Wolf KM, Busk MF, et al. Fiberoptic bronchoscopic cryotherapy in the management of tracheobronchial obstruction. Chest 1996; 110:718 –723 CHEST / 132 / 5 / NOVEMBER, 2007
1663
Broncholith Removal Using Cryotherapy During Flexible Bronchoscopy* A Case Report Anita J. Reddy, MD; Joseph A. Govert, MD; Thomas A. Sporn, MD; and Momen M. Wahidi, MD Pulmonary broncholithiasis can cause a management dilemma depending on its location and the possible involvement of vascular structures. Many patients www.chestjournal.org
undergo rigid bronchoscopy or surgical interventions for the removal of broncholiths. In this case report, we describe a 38-year-old white man with a history of performing warehouse demolitions who presented with chronic cough, dyspnea on exertion, and recurrent pneumonia. Imaging studies revealed hilar and mediastinal calcifications, as well as a calcification in the right middle lobe bronchus. Flexible bronchoscopy revealed a mobile obstructing calcified mass in the right middle lobe bronchus. Attempts at removing the mass with forceps were unsuccessful. Instead, the mass was removed using cryotherapy with minimal bleeding and complete resolution of the obstruction. Pathologic examination confirmed that the mass was a broncholith, and stains revealed the presence of histoplasma fungal forms. Partially attached broncholiths can be removed safely using flexible bronchoscopy with the aid of cryotherapy. (CHEST 2007; 132:1661–1663) Key words: broncholith; bronchoscopy; cryotherapy
male construction worker was referred to A our38-year-old institution for recurrent pneumonias and right
middle lobe obstruction. He had spent most of his life in Texas employed in construction and sheet metal fabrication, but he had spent a year in the Lexington, KY, area performing demolition work. Seven months prior to presentation at our institution, the patient reported symptoms of persistent dry cough, which then progressed to a cough productive of purulent sputum and dyspnea on exertion. He was treated with antibacterial therapy for right middle lobe pneumonia. Follow-up chest radiographs revealed persistent right middle lobe infiltrates; therefore, a chest CT scan was performed, revealing multiple calcified hilar and mediastinal lymph nodes, as well as obstruction of the right middle lobe bronchus in association with an area of calcification. Bronchoscopy was performed at the referring institution and revealed an obstruction of the right middle orifice by a mass that could not be removed. Endobronchial biopsies were performed, and pathology findings revealed significant calcium deposits. Symptoms of fever and productive cough again developed in the patient, and, due to his recurrent symptoms,
*From the Department of Medicine (Drs. Reddy, Govert, and Wahidi), Division of Pulmonary, Allergy and Critical Care Medicine, and the Department of Pathology (Dr. Sporn), Duke University Medical Center, Durham, NC. The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Manuscript received March 22, 2007; revision accepted April 18, 2007. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Anita J. Reddy, MD, Associate Staff, Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic Health System, 9500 Euclid Ave, Desk A90, Cleveland, OH 44195; e-mail: [email protected] DOI: 10.1378/chest.07-0739 CHEST / 132 / 5 / NOVEMBER, 2007
1661
he was referred to our institution for further evaluation. At the time of presentation to our clinic, he reported mild dry cough without hemoptysis and mild dyspnea on exertion. The findings of the physical examination were normal with normal oxygen saturation while breathing room air. A lung examination did not reveal any bronchial breath sounds, crackles, or wheezes. A chest CT scan (Fig 1) revealed marked calcification of hilar lymph nodes and the subcarinal lymph node, and an area of dense calcification obstructing the right middle lobe bronchus leading to near-complete collapse of the medial and lateral segments of the right middle lobe. Calcifications were also noted in the spleen. Repeat bronchoscopy at our institution revealed complete obstruction of the right middle lobe bronchus by a calcified mass, which was partially mobile within the bronchus (Fig 2). Attempts at removing the mass using forceps were unsuccessful. Cryotherapy was then employed as a means of removal. This resulted in near-complete removal of the mass with resolution of the obstruction, although a small remnant stalk continued to be present within the lateral wall of the right middle lobe bronchus. Coagulation of the stalk was not performed prior to cryotherapy since the stalk was not fully visualized prior to broncholith removal. Minimal bleeding was encountered after removal. Pathologic examination revealed fragments of chronically inflamed bronchial tissue with fibrocalcific debris consistent with a broncholith (Fig 3). Histochemical stains were positive for yeast, with morphology typical of Histoplasma capsulatum. This patient will be followed up for the recurrence of respiratory symptoms. If his cough should return, a follow-up bronchoscopy would be performed to detect the recurrence of broncholithiasis. A chest CT scan would also be considered to evaluate for associated complications of histoplasmosis such as granulomatous mediastinitis or progressive mediastinal fibrosis. Histoplasma is commonly cultured from calcified lymph nodes and broncholiths in asymptomatic patients, and no antimicrobial treatment is
Figure 2. Top, A: a bronchoscopic view showing the partially attached broncholith in the right middle lobe bronchus. Center, B: remnant stalk within the right middle lobe bronchus after removal of a broncholith. Bottom, C: extracted broncholith.
recommended unless evidence of chronic histoplasmosis or other complications such as granulomatous mediastinitis develops in the patient.1
Discussion
Figure 1. CT scan image (lung window) showing calcifications present within the right middle lobe bronchus and right hilar lymph nodes. 1662
Broncholithiasis is a rare disorder that is marked by hilar and/or parenchymal calcifications in response to an inflammatory process. Pulmonary tuberculosis is the most common cause of broncholithiasis worldwide, while histoplasmosis is the most common cause in the United States. Other causes include cryptococcus, coccidioidomycosis, actinomycosis, aspergillosis, nocardiosis, silicosis, and malignancy. Patients with broncholithiasis can present with a variety of symptoms. The most common symptoms include persistent cough, hemoptysis, recurrent pneumonia, wheezing, and dyspnea. Lithoptysis, or expectoration of small stones, is a rare but pathognomonic sign Selected Reports
Figure 3. Top, A: bronchial tissue with fibrocalcific and necrotic debris (following decalcification) [hematoxylin-eosin, original magnification ⫻100]. Bottom, B: yeast with morphology typical of H capsulatum (methenamine-silver, original magnification ⫻400).
of broncholithiasis. Broncholithiasis can result in a number of complications, including erosion of broncholiths into the bronchial wall, resulting in airway obstruction and/or hemoptysis, as well as erosion into the esophagus or vasculature. Chest radiographs can reveal calcification of the hilar and mediastinal lymph nodes, parenchymal calcification, or obstruction of the airways leading to atelectasis, mucoid impaction, bronchiectasis, or airtrapping. Other manifestations include migration or disappearance of a calcific focus. The management of broncholithiasis is dependent on the degree of symptoms as well as the size and location of the broncholiths. Possible interventions include flexible bronchoscopy, rigid bronchoscopy, and surgical management. Utilizing bronchoscopy for the removal of broncholiths can be difficult due to the embedding of the stone into surrounding structures, large size, and difficulty crushing the stone. Flexible bronchoscopy can be used to establish a diagnosis, as well as for the removal of broncholiths. Success rates using flexible bronchoscopy for the removal of broncholiths is reported to be approximately 30%, and there have been reports2– 4 utilizing balloon catheters and tripod forceps with success, especially in cases where a loose broncholith is present. Complications can include hemoptysis and central airway obstruction due to a loose stone. Rigid bronchoscopy is also employed for the removal of broncholiths with success rates ranging from 67 to 87%.5 Several institutions have described the use of Nd-YAG and holmium-YAG lasers to fragment large endobronchial stones.3,5 Complications associated with lasers include perforation of the bronchial wall and hemorrhage. www.chestjournal.org
A key question in the management of broncholiths is whether to attempt bronchoscopic removal or to proceed with surgical resection. One large retrospective series by Olsen et al4 identified the degree of attachment of the broncholith to the bronchial wall as a factor in the success rate of bronchoscopic removal. Bronchoscopic excision was successful in 48% of patients with partially eroding broncholiths and in 100% of those with loose broncholiths. Surgical treatment should be considered over bronchoscopic removal when patients present with hemoptysis, the broncholith is firmly attached to the bronchial wall, or bronchoscopic excision is not available or feasible. Preferred operative procedures include segmentectomy, followed by lobectomy and pneumonectomy.6,7 Complications include laceration of the pulmonary artery, esophageal perforation, and mainstem bronchus tear. In this case, we describe the first report of using cryotherapy during flexible bronchoscopy for the removal of a broncholith. Cryotherapy has been used for the removal of foreign objects, blood clots, granulation tissue, and mucous plugs,8 as well as the management of endobronchial obstruction.9 The advantages of cryotherapy include ease of use, lower cost compared to laser therapies, and reusability of the cryoprobe after disinfection. Complications can include bleeding or airway perforation, especially when intervention includes manipulation of the broncholith stalk. Caution should also be taken when using cryotherapy for this indication and should only be performed by experienced pulmonologists who have been trained in interventional bronchoscopy until further experience is gained and safety is established. Our experience in this patient indicates that cryotherapy can be an alternative treatment option in the removal of mobile or partially attached broncholiths with flexible bronchoscopy. This modality can be particularly useful when broncholiths are not easily amenable to removal with forceps extraction during flexible bronchoscopy.
References 1 Kauffman CA. Histoplasmosis: a clinical and laboratory update. Clin Micr Rev 2007, 20:115–132 2 Yi K, Lee H, Park S, et al. Two cases of broncholith removal under the guidance of flexible bronchoscopy. Korean J Intern Med 2005; 20:90 –91 3 Menivale F, Deslee G, Vallerand H, et al. Therapeutic management of broncholithiasis. Ann Thorac Surg 2005; 79:1774 –1776 4 Olson EJ, Utz JP, Prakash UB. Therapeutic bronchoscopy in broncholithiasis. Am J Respir Crit Care Med 1999; 160:766 –770 5 Ferguson JS, Rippentrop JM, Fallon B, et al. Management of obstructing pulmonary broncholithiasis with threedimensional imaging and holmium laser lithotripsy. Chest 2006; 130:909 –912 6 Faber L, Jensik R, Chawla S, et al. The surgical implication of broncholithiasis. J Thorac Cardiovasc Surg 1975; 70:779 –789 7 Potaris K, Miller DL, Trastek VF, et al. Role of surgical resection in broncholithiasis. Ann Thorac Surg 2000; 70:248 –251 8 Wahidi MM, Herth FJF, Ernst A. State of the art: interventional pulmonology. Chest 2007; 131:261–274 9 Mathur PN, Wolf KM, Busk MF, et al. Fiberoptic bronchoscopic cryotherapy in the management of tracheobronchial obstruction. Chest 1996; 110:718 –723 CHEST / 132 / 5 / NOVEMBER, 2007
1663