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Tracheal polyp
CASE REPORTS
Tracheal Polyp T. Clark Gamblin, MD, Lisa A. Farmer, MD, R. Jonathan Dean, MD, R. Andrew Bradley, MD, and Martin L. Dalton, MD Departments of Surgery, Medicine, and Pathology, Mercer University School of Medicine, Medical Center of Central Georgia, Macon, Georgia
Benign tumors of the tracheobronchial tree are extremely rare. A case of a benign inflammatory endotracheal polyp and literature review are presented, including classification and treatment options. Although rare, these lesions must be efficiently diagnosed and expeditiously removed to prevent airway occlusion or irreversible pulmonary disease. (Ann Thorac Surg 2002;73:1286 –7) © 2002 by The Society of Thoracic Surgeons
B
enign tumors of the tracheobronchial tree are distinctly uncommon. They may include respiratory papillomatous, granular cell myoblastoma, lipoma, fibroma, adenoma, leiomyoma, polyp, and hemangioma. Endobronchial polyps are rarely encountered since the introduction of antibiotics. The majority of polyps are amenable to bronchoscopic removal. When necessary, the lesion can be removed via thoracotomy or median sternotomy. A previously healthy 43-year-old man presented to our emergency center with increasing dyspnea and stridor. His complaint upon arrival was worsening shortness of breath and cough for 1 month. He had been forced to stop working as a carpenter because of increasing respiratory difficulties. Over the past year the patient had been seen at several emergency rooms, and had been hospitalized once after a near syncopal episode when his exertional dyspnea worsened because of a coughing and “choking” episode. He had been treated with intravenous antibiotics and nebulizer updrafts, with minimal improvement. The patient admitted to a 55 pack-year history of smoking but had quit over the past month secondary to his respiratory complaints. He reported no history of asthma or other pulmonary disease. Upon admission to our hospital the patient was in moderate respiratory distress, using accessory muscles for breathing. Respiratory rate was 22/min and oxygen saturation was 98% on room air. Stridor was present as well as mild bilateral rhonchi. An outpatient ENT evaluation performed the day before admission revealed no abnormalities in the oropharynx or larynx and the cords moved normally. Chest roentgenogram (anteroposterior view) was interpreted as normal. Workup for infectious causes of subglottic swelling was initiated, including blood and
Accepted for publication June 18, 2001. Address reprint requests to Dr Gamblin, Department of Surgery, Medical Center of Central Georgia, 777 Hemlock St, Hospital Box 140, Macon, GA 31201; e-mail: [email protected].
© 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
sputum cultures. Pulmonary medicine was consulted and bronchoscopy recommended. At fiberoptic bronchoscopy by the pulmonary consultant, a large smooth soft tissue mass almost completely occluding the distal trachea was readily identified. The purplish polypoid mass moved with respiration and had a “ball valve” effect. No attempt was made to pass the bronchoscope beyond the lesion for fear of airway compromise. Surgery was urgently consulted and the patient was taken from the endoscopy suite directly to the operating room. On quickly reviewing the patient’s radiologic studies, the tracheal mass was readily appreciated on the lateral chest x-rays (Fig 1). Removal of the tumor by means of a rigid bronchoscopy under general anesthesia proved to be impossible because of difficulty in effectively grasping this rubbery mass and failure to identify its short stalk. Using a fiberoptic bronchoscope, the airway was secured by passing a number 6 endotracheal tube beyond the mass. Median sternotomy was then performed, as this is our preferential management of an obstructing tumor at or near the carina [1]. Using a fiberoptic bronchoscope to transilluminate the site of the mass, the trachea was opened transversely at a level approximately 2 cm proximal to the carina. The tumor appeared to be grossly benign so only a small surrounding portion of the membranous trachea that included the base of the polyp was resected. The trachea was repaired primarily with interrupted 3-0 Vicryl sutures. The postoperative course was uneventful, and the patient was discharged home on day 3. He has had no further respiratory difficulty in follow-up, which now extends to 30 months. Pathologic examination confirmed a 3 ⫻ 2 ⫻ 1.5– cm pedunculated fibroepithelial inflammatory polyp. The lesion was lined by slightly thickened squamous mucosa and the underlying fibrovascular stroma contained prominent vessels (Fig 2). There was acute inflammation extending into the tracheal stroma but no significant epithelial atypia. The polyp and its entire stalk were completely excised with negative margins.
Comment Both malignant and benign tracheal or bronchial neoplasms can lead to airway compromise secondary to both intraluminal and extraluminal growth, with compromise of the airway. The majority of tracheal tumors in adults are malignant. Several reviews indicate an incidence of malignancy to be 80% to 90% [2]. Therefore benign tumors of the tracheobronchial tree are distinctly uncommon. A report from Mayo Clinic found 13 benign endobronchial tumors during 11,626 bronchoscopic procedures from 1945 to 1956. The most common benign neoplasm is recurrent respiratory papillomatosis [3]. Other benign tumors include granular cell myoblastoma, lipoma, fibroma, adenoma, leiomyoma, polyp, and hemangioma [2, 3]. Endobronchial polyps are rarely encountered. Patter0003-4975/02/$22.00 PII S0003-4975(01)03115-0
Ann Thorac Surg 2002;73:1286 –7
Fig 1. Lateral chest roentgenogram shows the tracheal mass, which was not visible on anteroposterior chest roentgenogram.
son first described this pathologic entity in 1930 and, by 1940, at least 40 cases had been reported [4]. Since the introduction of antibiotics, several reports show these polyps are seen much less frequently [5]. This can be explained by the fact that many believe the lesion is more inflammatory in nature than truly neoplastic. Peroni and Rosenberg postulated that the polyp forms when a break in the bronchial mucosa occurs. This is followed by granulation tissue and subsequent replacement by fibrous tissue and epithelialization [6]. The initial break in
Fig 2. The bisected tracheal polyp, 3 ⫻ 2 ⫻ 1.5-cm, with complete excision including a portion of tracheal cartilage (left).
CASE REPORT
GAMBLIN ET AL TRACHEAL POLYP
1287
the mucosa could be secondary to a foreign body, smoke inhalation, infectious causes, or other irritants [6, 7]. Classification of endobronchial polyps remains confusing. Drennan and Douglas devised a practical, simplified classification, which is generally accepted and divides tracheobronchial polyps into three distinct categories. These are multiple papillomatosis, solitary bronchial papilloma arising from normal bronchial epithelium [7], and inflammatory polyps as seen with our patient. Inflammatory polyps are solitary benign endobronchial lesions with stromal configuration consisting of well-formed fibrous connective tissue with or without inflammatory cell infiltration. These polyps are covered with stratified squamous epithelium or normal bronchial mucosa [8]. An investigation of six patients from Vanderbilt University found the average age of affected patients to be 46 years, with no gender predilection. Dyspnea was more common with inflammatory polyps which averaged 13 mm in length, compared with 4 mm for papillomas. Hemoptysis was also noted to be more common with papillomas [8]. Treatment of inflammatory polyps has varied widely. With small mildly symptomatic lesions, some have reported success with steroids and antibiotics [6, 7]. When more urgent relief of airway compromise is needed, the majority of polyps are amenable to bronchoscopic removal [8 –10]. When necessary, the lesion must be removed surgically by means of a thoracotomy or sternotomy [1]. In summary, we have learned once again that “all that wheezes is not asthma.” With even a modest index of suspicion, all patients with unexplained respiratory difficulties should have fiberoptic bronchoscopy even in presence of a normal chest roentgenogram. The value of the lateral chest roentgenogram is reinforced. If a polyp is diagnosed, expedient removal is recommended.
References 1. Bricker DL, Parker TM, Dalton ML. Cardiopulmonary bypass in anesthetic management of tracheal stenosis. Arch Surg 1979;114:847–9. 2. Stack PS, Steckler RM. Tracheal neurilemoma: case report and review of the literature. Head Neck 1990;12:436–9. 3. Miller DR. Benign tumors of lung and tracheobronchial tree. Collective review: Benign Pulm Tumors 1969;8:543–59. 4. Patterson EJ. Benign bronchial neoplasms: bronchoscopic aspects. Arch Otolaryng 1930;12:739 – 46. 5. Sears HF, Michaelis LL, Minor GR, Sweet DE. Endobronchial polyp: A case presentation. Thorac Cardiovasc Surg 1975;70:371–5. 6. Smith RE. Endobronchial polyp and chronic smoke injury. Postgrad Medical J 1989;65:785–7. 7. Berman DE, Wright ES, Edstrom HW. Endobronchial inflammatory polyp associated with a foreign body. Chest 1984;86:483– 4. 8. Freant LJ, Sawyer JL. Benign bronchial polyp and papillomas. Ann Thorac Surg 1971;11:460–7. 9. Kahan B, Amer NS. Multiple bronchial polyps. Chest 1970; 57:279– 83. 10. Tedeschi LG, Libertini R, Conte B. Endobronchial polyp. Chest 1973;63:110–2.
Tracheal Polyp T. Clark Gamblin, MD, Lisa A. Farmer, MD, R. Jonathan Dean, MD, R. Andrew Bradley, MD, and Martin L. Dalton, MD Departments of Surgery, Medicine, and Pathology, Mercer University School of Medicine, Medical Center of Central Georgia, Macon, Georgia
Benign tumors of the tracheobronchial tree are extremely rare. A case of a benign inflammatory endotracheal polyp and literature review are presented, including classification and treatment options. Although rare, these lesions must be efficiently diagnosed and expeditiously removed to prevent airway occlusion or irreversible pulmonary disease. (Ann Thorac Surg 2002;73:1286 –7) © 2002 by The Society of Thoracic Surgeons
B
enign tumors of the tracheobronchial tree are distinctly uncommon. They may include respiratory papillomatous, granular cell myoblastoma, lipoma, fibroma, adenoma, leiomyoma, polyp, and hemangioma. Endobronchial polyps are rarely encountered since the introduction of antibiotics. The majority of polyps are amenable to bronchoscopic removal. When necessary, the lesion can be removed via thoracotomy or median sternotomy. A previously healthy 43-year-old man presented to our emergency center with increasing dyspnea and stridor. His complaint upon arrival was worsening shortness of breath and cough for 1 month. He had been forced to stop working as a carpenter because of increasing respiratory difficulties. Over the past year the patient had been seen at several emergency rooms, and had been hospitalized once after a near syncopal episode when his exertional dyspnea worsened because of a coughing and “choking” episode. He had been treated with intravenous antibiotics and nebulizer updrafts, with minimal improvement. The patient admitted to a 55 pack-year history of smoking but had quit over the past month secondary to his respiratory complaints. He reported no history of asthma or other pulmonary disease. Upon admission to our hospital the patient was in moderate respiratory distress, using accessory muscles for breathing. Respiratory rate was 22/min and oxygen saturation was 98% on room air. Stridor was present as well as mild bilateral rhonchi. An outpatient ENT evaluation performed the day before admission revealed no abnormalities in the oropharynx or larynx and the cords moved normally. Chest roentgenogram (anteroposterior view) was interpreted as normal. Workup for infectious causes of subglottic swelling was initiated, including blood and
Accepted for publication June 18, 2001. Address reprint requests to Dr Gamblin, Department of Surgery, Medical Center of Central Georgia, 777 Hemlock St, Hospital Box 140, Macon, GA 31201; e-mail: [email protected].
© 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
sputum cultures. Pulmonary medicine was consulted and bronchoscopy recommended. At fiberoptic bronchoscopy by the pulmonary consultant, a large smooth soft tissue mass almost completely occluding the distal trachea was readily identified. The purplish polypoid mass moved with respiration and had a “ball valve” effect. No attempt was made to pass the bronchoscope beyond the lesion for fear of airway compromise. Surgery was urgently consulted and the patient was taken from the endoscopy suite directly to the operating room. On quickly reviewing the patient’s radiologic studies, the tracheal mass was readily appreciated on the lateral chest x-rays (Fig 1). Removal of the tumor by means of a rigid bronchoscopy under general anesthesia proved to be impossible because of difficulty in effectively grasping this rubbery mass and failure to identify its short stalk. Using a fiberoptic bronchoscope, the airway was secured by passing a number 6 endotracheal tube beyond the mass. Median sternotomy was then performed, as this is our preferential management of an obstructing tumor at or near the carina [1]. Using a fiberoptic bronchoscope to transilluminate the site of the mass, the trachea was opened transversely at a level approximately 2 cm proximal to the carina. The tumor appeared to be grossly benign so only a small surrounding portion of the membranous trachea that included the base of the polyp was resected. The trachea was repaired primarily with interrupted 3-0 Vicryl sutures. The postoperative course was uneventful, and the patient was discharged home on day 3. He has had no further respiratory difficulty in follow-up, which now extends to 30 months. Pathologic examination confirmed a 3 ⫻ 2 ⫻ 1.5– cm pedunculated fibroepithelial inflammatory polyp. The lesion was lined by slightly thickened squamous mucosa and the underlying fibrovascular stroma contained prominent vessels (Fig 2). There was acute inflammation extending into the tracheal stroma but no significant epithelial atypia. The polyp and its entire stalk were completely excised with negative margins.
Comment Both malignant and benign tracheal or bronchial neoplasms can lead to airway compromise secondary to both intraluminal and extraluminal growth, with compromise of the airway. The majority of tracheal tumors in adults are malignant. Several reviews indicate an incidence of malignancy to be 80% to 90% [2]. Therefore benign tumors of the tracheobronchial tree are distinctly uncommon. A report from Mayo Clinic found 13 benign endobronchial tumors during 11,626 bronchoscopic procedures from 1945 to 1956. The most common benign neoplasm is recurrent respiratory papillomatosis [3]. Other benign tumors include granular cell myoblastoma, lipoma, fibroma, adenoma, leiomyoma, polyp, and hemangioma [2, 3]. Endobronchial polyps are rarely encountered. Patter0003-4975/02/$22.00 PII S0003-4975(01)03115-0
Ann Thorac Surg 2002;73:1286 –7
Fig 1. Lateral chest roentgenogram shows the tracheal mass, which was not visible on anteroposterior chest roentgenogram.
son first described this pathologic entity in 1930 and, by 1940, at least 40 cases had been reported [4]. Since the introduction of antibiotics, several reports show these polyps are seen much less frequently [5]. This can be explained by the fact that many believe the lesion is more inflammatory in nature than truly neoplastic. Peroni and Rosenberg postulated that the polyp forms when a break in the bronchial mucosa occurs. This is followed by granulation tissue and subsequent replacement by fibrous tissue and epithelialization [6]. The initial break in
Fig 2. The bisected tracheal polyp, 3 ⫻ 2 ⫻ 1.5-cm, with complete excision including a portion of tracheal cartilage (left).
CASE REPORT
GAMBLIN ET AL TRACHEAL POLYP
1287
the mucosa could be secondary to a foreign body, smoke inhalation, infectious causes, or other irritants [6, 7]. Classification of endobronchial polyps remains confusing. Drennan and Douglas devised a practical, simplified classification, which is generally accepted and divides tracheobronchial polyps into three distinct categories. These are multiple papillomatosis, solitary bronchial papilloma arising from normal bronchial epithelium [7], and inflammatory polyps as seen with our patient. Inflammatory polyps are solitary benign endobronchial lesions with stromal configuration consisting of well-formed fibrous connective tissue with or without inflammatory cell infiltration. These polyps are covered with stratified squamous epithelium or normal bronchial mucosa [8]. An investigation of six patients from Vanderbilt University found the average age of affected patients to be 46 years, with no gender predilection. Dyspnea was more common with inflammatory polyps which averaged 13 mm in length, compared with 4 mm for papillomas. Hemoptysis was also noted to be more common with papillomas [8]. Treatment of inflammatory polyps has varied widely. With small mildly symptomatic lesions, some have reported success with steroids and antibiotics [6, 7]. When more urgent relief of airway compromise is needed, the majority of polyps are amenable to bronchoscopic removal [8 –10]. When necessary, the lesion must be removed surgically by means of a thoracotomy or sternotomy [1]. In summary, we have learned once again that “all that wheezes is not asthma.” With even a modest index of suspicion, all patients with unexplained respiratory difficulties should have fiberoptic bronchoscopy even in presence of a normal chest roentgenogram. The value of the lateral chest roentgenogram is reinforced. If a polyp is diagnosed, expedient removal is recommended.
References 1. Bricker DL, Parker TM, Dalton ML. Cardiopulmonary bypass in anesthetic management of tracheal stenosis. Arch Surg 1979;114:847–9. 2. Stack PS, Steckler RM. Tracheal neurilemoma: case report and review of the literature. Head Neck 1990;12:436–9. 3. Miller DR. Benign tumors of lung and tracheobronchial tree. Collective review: Benign Pulm Tumors 1969;8:543–59. 4. Patterson EJ. Benign bronchial neoplasms: bronchoscopic aspects. Arch Otolaryng 1930;12:739 – 46. 5. Sears HF, Michaelis LL, Minor GR, Sweet DE. Endobronchial polyp: A case presentation. Thorac Cardiovasc Surg 1975;70:371–5. 6. Smith RE. Endobronchial polyp and chronic smoke injury. Postgrad Medical J 1989;65:785–7. 7. Berman DE, Wright ES, Edstrom HW. Endobronchial inflammatory polyp associated with a foreign body. Chest 1984;86:483– 4. 8. Freant LJ, Sawyer JL. Benign bronchial polyp and papillomas. Ann Thorac Surg 1971;11:460–7. 9. Kahan B, Amer NS. Multiple bronchial polyps. Chest 1970; 57:279– 83. 10. Tedeschi LG, Libertini R, Conte B. Endobronchial polyp. Chest 1973;63:110–2.