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Transtracheal migration of an intravertebral Steinmann pin to the left bronchus
Volume 93 Number 6 June 1987
Brief communications
939
Fig. 3. The present patient's reactive hyperemia tests for the left anterior descending (LAD) coronary artery are shown. The left panel. before placement of the coronary bypass graft, demonstrates a nearly flat reactive hyperemia phase. This correlates with a high degree of obstruction in this vessel. Right panel. After restoration of coronary blood flow and termination of cardiopulmonary bypass, repeat observation was made and this demonstrated dramatic improvement in the reactive hyperemia trace. This characteristically does not return entirely to what can be expected in a normal vessel but is dramatically improved.
available, one has the possibility of more accurate assessment of the need for and placement of bypass grafts. In addition, if the hemodynamics were entirely normal in the vessels studied, these need not be grafted, which would save time and unnecessary effort. current efforts are being devoted to improvements in the Doppler technique, which it is hoped will allow routine hemodynamic assessment of posterior vessels in elective as well as in unusual cases. Some high obtuse marginal branches of the circumflex artery can currently be studied if the probe can be held in place and reactive hyperemia induced. REFERENCES 1. Wright C, Doty D, Eastham C, Laughlin D, Krumm P, Marcus M. A method for assessing the physiological significance of coronary obstructions in man at cardiac surgery. Circulation 1980;62(Pt 2):1111-5. 2. Wright CB, Doty DB, Eastham CL, Marcus ML. Measurements of coronary reactive hyperemia with a Doppler probe: intraoperative guide to hemodynamically significant lesions. J THORAC CARDIOVASC SURG 1980; 80:888-97. 3. White CW, Wright CB, Doty DB, et al. Does visual interpretation of the coronary arteriogram predict the physiologic importance of a coronary stenosis? N Engl J Med 1984;310:819-24. 4. Marcus M, Wright C, Doty D, et al. Measurements of coronary velocity and reactive hyperemia in the coronary circulation of humans. Circ Res 1981;49:877-91. 5. Marcus ML, Gascho JA, Mueller TM, et al. The effects of ventricular hypertrophy on the coronary circulation. Basic Res Cardiol 1981;76:575-81. 6. Wright CB, Hiratzka LF, Doty DB, White CW, Eastham CL, Marcus ML. Coronary hemodynamics in patients undergoing coronary artery bypass graft surgery. In: Rob-
erts AJ, ed. The new technologies in the evaluation and management of coronary artery bypass graft surgery. Chicago: Year Book Medical Publishers, 1983:437-46.
Transtracheal migration of an intravertebral Steinmann pin to the left bronchus Michael Richardson, M.B.B.S., Mario Gomes, M.D., and Edward Tsou, M.D., Washington, D. C. From the Departments of Medicine and Surgery, Georgetown University Medical Center, Washington, D. C.
Foreign body aspiration only rarely occurs by migration into the lung from other sites in the body. This report describes the migration of an intracervical Steinmann pin through the posterior tracheal membrane into the left bronchus and its successful removal via the rigid bronchoscope.
Entry of foreign bodies into the lungs and bronchial tree most commonly occurs by aspiration or penetration through the chest wall.':' Rarely, pulmonary embolization of distantly placed missiles such as bullets'" or invasion of the pleura, lungs, and mediastinum by orthopedic stabilizing devices from the shoulder joints occurs.':" We describe the migration of an intravertebral Steinmann pin through the posterior tracheal wall to the left bronchus and its removal.
Address for reprints: Edward Tsou, M.D., Pulmonary Division, Georgetown University Medical Center, 3800 Reservoir Rd., N.W., Washington, D. C. 20057.
The Journal of
940
Brief communications
Thoracic and Cardiovascular Surgery
other tracheobronchial abnormalities were noted. The pin was not reinserted, the neck was stabilized by a cervical collar, and the patient made an uneventful recovery.
Fig. 1. Lateral neck roentgenogram, following first stabilization, showing position of Steinmann pin. Case report. A 72-year-old man was admitted for progressive weakness, numbness, and pain in the upper extremities of 3 weeks' duration. An obstructing chordoma at the levelof the fifth cervical vertebra was removed by an anterior approach. The cervical spine was stabilized by a Steinmann pin, which was fused into the fifth, sixth, and seventh cervical vertebrae by methylmethacrylate. A postoperative roentgenogram demonstrated that the cervical vertebrae and Steinmann pin were in satisfactory position (Fig. 1). Three days later the patient complained of a mildly sore throat, but he was able to eat and swallow without difficulty. A routine chest roentgenogram on the fourth postoperative day demonstrated the Steinmann pin in the left main bronchus with the point cephalad instead of in its previous caudad orientation in the vertebrae (Fig. 2). No symptoms were noted by the patient. In the operating room, general anesthesia was administered, nasotracheal intubation accomplished, and a neurosurgeon manually stabilized and carefully hyperextended the neck. Fiberoptic endoscopy showed the pin in the left main bronchus, point cephalad, surrounded by erythema and edema. While optimal position of the neck was maintained by the neurosurgeon, the patient was extubated and a rigid bronchoscope was inserted by a thoracic surgeon. The pin was retrieved with a claw forceps. A lacerated, erythematous area in the posterior wall of the mid-trachea was observed and believed to be the site of penetration of the Steinmann pin. No
Comment. Displacement of acrylic grafts, pins, and rods is a recognized complication of spinal fixation, especially when used for malignant disease.'! 12 Although relocation of orthopedic stabilizing devices to the lungs by penetration through the pleura has occurred,"? migration of an intravertebral foreign body through the walls of the esophagus and trachea into the bronchial tree has not been reported. In this patient the pin not only perforated the posterior tracheal wall but rotated along its long axis as well. Perhaps the pin was initially aspirated into the right bronchus and due to position change, respiration, or cough, fell backward into its final position in the left bronchus. Despite neck instability, rigid bronchoscopy and retrieval 'of the pin were successful. The rigid bronchoscope remains the instrument of choice for removing large foreign bodies, whereas small and distally located objects can be extracted with flexible instruments.":" Cervical instability made hyperextension of the neck for positioning the rigid bronchoscope potentially hazardous, and use of a fiberoptic bronchoscope to remove the pin was considered. However, the size and shape of the pin suggested that it would be difficult to extract with a small forceps. Subsequently, however, we were able to grasp and maneuver a similar Steinmann pin from a bronchial tree model with an alligator forceps. Occasionally bronchoscopy cannot be performed because of upper airway obstruction or neck immobility, or large foreign bodies cannot be negotiated through the subglottic or pharyngeal areas, which necessitates their removal through a tracheostomy" or thoracotomy. This was not necessary.
1.
2.
3. 4. 5.
6.
REFERENCES Aytac C, Yaurdakul Y, Ikizler C, Olga R, Saylem A. Inhalation of foreign bodies in children: report of 500 cases. J THORAC CARDlOVASC SURG 1977;74:145-51. Wolkove N, Kreisman H, Cohen C, Frank H. Occult foreign-body aspiration in adults. JAMA 1982;248:13502. Bogedain W. Migration of schrapnel from lung to bronchus. JAMA 1984;251:1862-3. Patten EL, Morales HE. Bullet emboli to the pulmonary artery: a rare occurrence. J Trauma 1982;22:801-2. Bernini CO, Junqueira AR Jr, Horita LT, Birolini D, Branco PD, de Oliveira MR. Pulmonary embolism from gunshot missiles. Surg Gynecol Obstet 1983;156:615-9. Goldman RL, Carmody RF. Foreign body pulmonary embolism originating from a gunshot wound to the head. J Trauma 1984;24:277-9.
Volume 93 Number 6 June 1987
Brief communications
941
Fig. 2. Anteroposterior (A) and lateral (B) chest roentgenograms. The pin is located in the left main bronchus. 7. Tristan TA, Daughtridge TG. Migration of a metallic pin from the humerus into the lung. N Engl J Med 1964;270:987-9. 8. McCaughan JS Jr, Miller PRo Migration of a Steinmann pin from the shoulder region into the lung [Letter] . JAMA 1969;207:1917. 9. Mazer R Jr. Migration of a Kirschner wire from the shoulder region into the lung: report of two cases. J Bone Joint Surg 1943;25:477-83. 10. Burman M, Grossman S, Rosenak S. The migration of a fracture-transfixing pin from the humerus into the mediastinum. AJR 1956;76:1061-5. 11. Harrington KD. The use of methylmethacrylate for vertebral-body replacement and anterior stabilization of pathological fracture-dislocations of the spine due to metastatic malignant disease. J Bone Joint Surg (Am) 1981;63:36-46.
12. Harrington KD. Anterior cord decompression and spinal stabilization for patients with metastatic lesions of the spine. J Neurosurg 1984;61:107-17. 13. Zavala DC, Rhodes ML. Foreign body removal: a new role for fiberoptic bronchoscopy. Ann Otol Rhinol Laryngol 1975;84:650-6. 14. Cunanan DS: Flexible fiberoptic bronchoscope in foreign body removal (300 cases). Chest 1978;73:725-6. 15. Simpson GT: Rigid vs fiberoptic bronchoscopy for foreign body aspiration [Letter]. N Engl J Med 1984;310:11901. 16. Swensson EE, Rah KH, Kim MC, Brooks JW, Salzberg AM. Extraction of large tracheal foreign bodies through a tracheostoma under bronchoscopic control. Ann Thorac Surg 1985;39:251-3.
Brief communications
939
Fig. 3. The present patient's reactive hyperemia tests for the left anterior descending (LAD) coronary artery are shown. The left panel. before placement of the coronary bypass graft, demonstrates a nearly flat reactive hyperemia phase. This correlates with a high degree of obstruction in this vessel. Right panel. After restoration of coronary blood flow and termination of cardiopulmonary bypass, repeat observation was made and this demonstrated dramatic improvement in the reactive hyperemia trace. This characteristically does not return entirely to what can be expected in a normal vessel but is dramatically improved.
available, one has the possibility of more accurate assessment of the need for and placement of bypass grafts. In addition, if the hemodynamics were entirely normal in the vessels studied, these need not be grafted, which would save time and unnecessary effort. current efforts are being devoted to improvements in the Doppler technique, which it is hoped will allow routine hemodynamic assessment of posterior vessels in elective as well as in unusual cases. Some high obtuse marginal branches of the circumflex artery can currently be studied if the probe can be held in place and reactive hyperemia induced. REFERENCES 1. Wright C, Doty D, Eastham C, Laughlin D, Krumm P, Marcus M. A method for assessing the physiological significance of coronary obstructions in man at cardiac surgery. Circulation 1980;62(Pt 2):1111-5. 2. Wright CB, Doty DB, Eastham CL, Marcus ML. Measurements of coronary reactive hyperemia with a Doppler probe: intraoperative guide to hemodynamically significant lesions. J THORAC CARDIOVASC SURG 1980; 80:888-97. 3. White CW, Wright CB, Doty DB, et al. Does visual interpretation of the coronary arteriogram predict the physiologic importance of a coronary stenosis? N Engl J Med 1984;310:819-24. 4. Marcus M, Wright C, Doty D, et al. Measurements of coronary velocity and reactive hyperemia in the coronary circulation of humans. Circ Res 1981;49:877-91. 5. Marcus ML, Gascho JA, Mueller TM, et al. The effects of ventricular hypertrophy on the coronary circulation. Basic Res Cardiol 1981;76:575-81. 6. Wright CB, Hiratzka LF, Doty DB, White CW, Eastham CL, Marcus ML. Coronary hemodynamics in patients undergoing coronary artery bypass graft surgery. In: Rob-
erts AJ, ed. The new technologies in the evaluation and management of coronary artery bypass graft surgery. Chicago: Year Book Medical Publishers, 1983:437-46.
Transtracheal migration of an intravertebral Steinmann pin to the left bronchus Michael Richardson, M.B.B.S., Mario Gomes, M.D., and Edward Tsou, M.D., Washington, D. C. From the Departments of Medicine and Surgery, Georgetown University Medical Center, Washington, D. C.
Foreign body aspiration only rarely occurs by migration into the lung from other sites in the body. This report describes the migration of an intracervical Steinmann pin through the posterior tracheal membrane into the left bronchus and its successful removal via the rigid bronchoscope.
Entry of foreign bodies into the lungs and bronchial tree most commonly occurs by aspiration or penetration through the chest wall.':' Rarely, pulmonary embolization of distantly placed missiles such as bullets'" or invasion of the pleura, lungs, and mediastinum by orthopedic stabilizing devices from the shoulder joints occurs.':" We describe the migration of an intravertebral Steinmann pin through the posterior tracheal wall to the left bronchus and its removal.
Address for reprints: Edward Tsou, M.D., Pulmonary Division, Georgetown University Medical Center, 3800 Reservoir Rd., N.W., Washington, D. C. 20057.
The Journal of
940
Brief communications
Thoracic and Cardiovascular Surgery
other tracheobronchial abnormalities were noted. The pin was not reinserted, the neck was stabilized by a cervical collar, and the patient made an uneventful recovery.
Fig. 1. Lateral neck roentgenogram, following first stabilization, showing position of Steinmann pin. Case report. A 72-year-old man was admitted for progressive weakness, numbness, and pain in the upper extremities of 3 weeks' duration. An obstructing chordoma at the levelof the fifth cervical vertebra was removed by an anterior approach. The cervical spine was stabilized by a Steinmann pin, which was fused into the fifth, sixth, and seventh cervical vertebrae by methylmethacrylate. A postoperative roentgenogram demonstrated that the cervical vertebrae and Steinmann pin were in satisfactory position (Fig. 1). Three days later the patient complained of a mildly sore throat, but he was able to eat and swallow without difficulty. A routine chest roentgenogram on the fourth postoperative day demonstrated the Steinmann pin in the left main bronchus with the point cephalad instead of in its previous caudad orientation in the vertebrae (Fig. 2). No symptoms were noted by the patient. In the operating room, general anesthesia was administered, nasotracheal intubation accomplished, and a neurosurgeon manually stabilized and carefully hyperextended the neck. Fiberoptic endoscopy showed the pin in the left main bronchus, point cephalad, surrounded by erythema and edema. While optimal position of the neck was maintained by the neurosurgeon, the patient was extubated and a rigid bronchoscope was inserted by a thoracic surgeon. The pin was retrieved with a claw forceps. A lacerated, erythematous area in the posterior wall of the mid-trachea was observed and believed to be the site of penetration of the Steinmann pin. No
Comment. Displacement of acrylic grafts, pins, and rods is a recognized complication of spinal fixation, especially when used for malignant disease.'! 12 Although relocation of orthopedic stabilizing devices to the lungs by penetration through the pleura has occurred,"? migration of an intravertebral foreign body through the walls of the esophagus and trachea into the bronchial tree has not been reported. In this patient the pin not only perforated the posterior tracheal wall but rotated along its long axis as well. Perhaps the pin was initially aspirated into the right bronchus and due to position change, respiration, or cough, fell backward into its final position in the left bronchus. Despite neck instability, rigid bronchoscopy and retrieval 'of the pin were successful. The rigid bronchoscope remains the instrument of choice for removing large foreign bodies, whereas small and distally located objects can be extracted with flexible instruments.":" Cervical instability made hyperextension of the neck for positioning the rigid bronchoscope potentially hazardous, and use of a fiberoptic bronchoscope to remove the pin was considered. However, the size and shape of the pin suggested that it would be difficult to extract with a small forceps. Subsequently, however, we were able to grasp and maneuver a similar Steinmann pin from a bronchial tree model with an alligator forceps. Occasionally bronchoscopy cannot be performed because of upper airway obstruction or neck immobility, or large foreign bodies cannot be negotiated through the subglottic or pharyngeal areas, which necessitates their removal through a tracheostomy" or thoracotomy. This was not necessary.
1.
2.
3. 4. 5.
6.
REFERENCES Aytac C, Yaurdakul Y, Ikizler C, Olga R, Saylem A. Inhalation of foreign bodies in children: report of 500 cases. J THORAC CARDlOVASC SURG 1977;74:145-51. Wolkove N, Kreisman H, Cohen C, Frank H. Occult foreign-body aspiration in adults. JAMA 1982;248:13502. Bogedain W. Migration of schrapnel from lung to bronchus. JAMA 1984;251:1862-3. Patten EL, Morales HE. Bullet emboli to the pulmonary artery: a rare occurrence. J Trauma 1982;22:801-2. Bernini CO, Junqueira AR Jr, Horita LT, Birolini D, Branco PD, de Oliveira MR. Pulmonary embolism from gunshot missiles. Surg Gynecol Obstet 1983;156:615-9. Goldman RL, Carmody RF. Foreign body pulmonary embolism originating from a gunshot wound to the head. J Trauma 1984;24:277-9.
Volume 93 Number 6 June 1987
Brief communications
941
Fig. 2. Anteroposterior (A) and lateral (B) chest roentgenograms. The pin is located in the left main bronchus. 7. Tristan TA, Daughtridge TG. Migration of a metallic pin from the humerus into the lung. N Engl J Med 1964;270:987-9. 8. McCaughan JS Jr, Miller PRo Migration of a Steinmann pin from the shoulder region into the lung [Letter] . JAMA 1969;207:1917. 9. Mazer R Jr. Migration of a Kirschner wire from the shoulder region into the lung: report of two cases. J Bone Joint Surg 1943;25:477-83. 10. Burman M, Grossman S, Rosenak S. The migration of a fracture-transfixing pin from the humerus into the mediastinum. AJR 1956;76:1061-5. 11. Harrington KD. The use of methylmethacrylate for vertebral-body replacement and anterior stabilization of pathological fracture-dislocations of the spine due to metastatic malignant disease. J Bone Joint Surg (Am) 1981;63:36-46.
12. Harrington KD. Anterior cord decompression and spinal stabilization for patients with metastatic lesions of the spine. J Neurosurg 1984;61:107-17. 13. Zavala DC, Rhodes ML. Foreign body removal: a new role for fiberoptic bronchoscopy. Ann Otol Rhinol Laryngol 1975;84:650-6. 14. Cunanan DS: Flexible fiberoptic bronchoscope in foreign body removal (300 cases). Chest 1978;73:725-6. 15. Simpson GT: Rigid vs fiberoptic bronchoscopy for foreign body aspiration [Letter]. N Engl J Med 1984;310:11901. 16. Swensson EE, Rah KH, Kim MC, Brooks JW, Salzberg AM. Extraction of large tracheal foreign bodies through a tracheostoma under bronchoscopic control. Ann Thorac Surg 1985;39:251-3.