- Email: [email protected]
Upper airway mass mimicking near-fatal asthma
104
Letters to the Editor
REFERENCES 1. Reid C, Chan L. Emergency Medicine terminology in the United Kingdom—time to follow the trend? Emerg Med J 2001;18:79 – 80. 2. Curry C. Accident—an anachronism? Arch Emerg Med 1992;9: 331–2.
e LATERAL CHEST RADIOGRAPHS FOR DETECTING PNEUMOTHORAX IN SUPINE TRAUMA PATIENTS e To the Editor: In a recent issue of this journal, Henderson and Shoenberger reported on a case of a pneumothorax that was initially missed on the supine chest film (1), a problem that has also been documented by others (2,3). As Henderson and Shoenberger indicate, most of these pneumothoraces are subsequently detected by computed tomography (CT) imaging, but the delay in diagnosis can lead to complications including progression to tension pneumothorax and death, particularly among intubated patients receiving positivepressure ventilation (4). It would be preferable to diagnose the pneumothorax in the Emergency Department before leaving for the CT scanner. There is extensive discussion in the Radiology literature regarding optimal patient positioning for the detection of pneumothorax, and supine anterior-posterior imaging is widely regarded to be among the least sensitive (5). Erect antero-posterior and left lateral decubitus images are more sensitive, but are contraindicated in patients who may harbor spine injuries, are intubated, or exhibit hemodynamic instability (6,7). Fortunately, lateral “shoot-through” radiographs are very sensitive for detecting a pneumothorax (8,9). Patients are imaged in the supine position in a manner similar to that used in cross-table lateral spine imaging, but with the x-ray beam positioned approximately 6 inches caudad, in alignment with the patient’s axillae. Imaging should take less than 30 s. The supine lateral chest radiograph can increase the detection of anterio-medial and subpulmonic pneumothoraces—the most common sites of pneumothorax in supine patients, and allow clinicians to definitively address related issues before leaving the resuscitation area (10). Patients may still need a chest CT scan to evaluate other injuries, and CT imaging may occasionally detect a pneumothorax that was not visible on supine lateral radiographs. Moreover, it is sometimes difficult to lateralize the pneumothorax on the lateral film if there are not other indicators (rib fractures, stab wounds, gunshots) of which side has the injury. However, there is still utility of this rapid, easilyperformed and interpreted, low radiation study for improving our detection of pneumothorax in the ED.
Edward S. Cotner, MD Olive View/UCLA Emergency Medicine Residency Program Los Angeles, California doi:10.1016/j.jemermed.2005.03.003
REFERENCES 1. Henderson S, Shoenberger J. Anterior pneumothorax and a negative chest x-ray in trauma. J Emerg Med 2004;26:231–2. 2. Kane T, Nuttall M, Bowyer R, Patel V. Failure of detection of pneumothorax on initial chest radiograph. Emerg Med J 2002;19: 468 –9. 3. Collins J, Samra G. Failure of chest X-rays to diagnose pneumothoraces after blunt trauma. Anaesthesia 1998;53:774 – 8. 4. Bridges K, Welch G, Silver M, Schinco M, Esposito B. CT detection of pneumothorax in multiple trauma patients. J Emerg Med 1993;11:179 – 86. 5. Tocino I. Pneumothorax in the supine patient. Radiographics 1985; 5:557– 86. 6. Carr J, Reed J, Choplin R, Pope T, Case L. Plain and computed radiography for detecting experimentally induced pneumothorax in cadavers: implications for detection in patients. Radiology 1992; 183:193–9. 7. Glazer H, Anderson D, Wilson B, Molina P, Sagel S. Pneumothorax: apperance on lateral chest radiographs. Radiology 1989;173: 707–11. 8. Morgan R, Owens C, Collins C, Evans W, Hansell D. Detection of pneumothorax with lateral shoot-through digital radiography. Clin Radiol 1993;48:249 –52. 9. Hoffer F, Ablow R. The cross-table lateral view in neonatal pneumothorax. AJR Am J Roentgenol 1984;142:1283– 6. 10. Tocino I, Miller M, Fairfax W, Distribution of pneumothorax in the supine and semirecumbent critically ill adult. AJR Am J Roentgenol 1985;144:901–5.
e UPPER AIRWAY MASS MIMICKING NEAR-FATAL ASTHMA e To the Editor: We read with interest the article by Kokturk et al. (1) on subglottic mass mimicking near-fatal asthma. We would like to share our experience by describing a case of upper airway mass mimicking near-fatal asthma. A 62-year-old woman went to a hospital with wheezing, shortness of breath, and dry cough. She was diagnosed with bronchial asthma and her symptoms seemed to improve slightly after use of bronchodilators. One year later, however, she developed acute onset of severe respiratory distress and bloody sputum. A computed tomography (CT) scan of the neck and chest showed a tumor at the isthmus of the thyroid gland and an intratracheal mass having the same density as the tumor and obstructing almost the entire lumen at the level of the fifth cervical vertebra. The patient was referred to our hospital. On admission, she was critically ill, frightened, and tachypneic, using accessory respiratory muscles and
The Journal of Emergency Medicine
speaking in one-word sentences. The patient underwent bronchoscopy that showed a hemorrhagic mass almost completely obstructing the tracheal lumen. Using the scope, an endobronchial tube was placed without delay, but sufficient material was not obtained to be able to diagnose the mass pathologically. Thereafter, total thyroidectomy with sleeve resection of the cervical trachea was carried out. The tumor was successfully removed and histological examination revealed a papillary carcinoma of the thyroid. Now, 14 years after the operation, the patient remains well. Bronchial asthma is a common illness in society and often patients are labeled “asthmatic” without appropriate evaluation. Slowly growing upper airway tumors are often misdiagnosed and treated as bronchial asthma. The case report by Kokturk et al. (1) and our case emphasize the fact that not all wheezes are attributable to asthma. It is important to bear in mind that upper airway obstructions can lead to asthma-like
105
symptoms in which establishment of the correct diagnosis may be challenging. Gen Ohara, MD Hiroaki Satoh, MD Katsunori Kagohashi, MD Morio Ohtsuka, MD Kiyohisa Sekizawa, MD Division of Respiratory Medicine Institute of Clinical Medicine University of Tsukuba Tsukuba-city, Ibaraki, Japan doi:10.1016/j.jemermed.2005.03.005 REFERENCE 1. Kokturk N, Demir N, Kervan F, Dinc E, Koybasioglu A, Turktas H. A subglottic mass mimicking near-fatal asthma: a challenge of diagnosis. J Emerg Med 2004;26:57– 60.
Letters to the Editor
REFERENCES 1. Reid C, Chan L. Emergency Medicine terminology in the United Kingdom—time to follow the trend? Emerg Med J 2001;18:79 – 80. 2. Curry C. Accident—an anachronism? Arch Emerg Med 1992;9: 331–2.
e LATERAL CHEST RADIOGRAPHS FOR DETECTING PNEUMOTHORAX IN SUPINE TRAUMA PATIENTS e To the Editor: In a recent issue of this journal, Henderson and Shoenberger reported on a case of a pneumothorax that was initially missed on the supine chest film (1), a problem that has also been documented by others (2,3). As Henderson and Shoenberger indicate, most of these pneumothoraces are subsequently detected by computed tomography (CT) imaging, but the delay in diagnosis can lead to complications including progression to tension pneumothorax and death, particularly among intubated patients receiving positivepressure ventilation (4). It would be preferable to diagnose the pneumothorax in the Emergency Department before leaving for the CT scanner. There is extensive discussion in the Radiology literature regarding optimal patient positioning for the detection of pneumothorax, and supine anterior-posterior imaging is widely regarded to be among the least sensitive (5). Erect antero-posterior and left lateral decubitus images are more sensitive, but are contraindicated in patients who may harbor spine injuries, are intubated, or exhibit hemodynamic instability (6,7). Fortunately, lateral “shoot-through” radiographs are very sensitive for detecting a pneumothorax (8,9). Patients are imaged in the supine position in a manner similar to that used in cross-table lateral spine imaging, but with the x-ray beam positioned approximately 6 inches caudad, in alignment with the patient’s axillae. Imaging should take less than 30 s. The supine lateral chest radiograph can increase the detection of anterio-medial and subpulmonic pneumothoraces—the most common sites of pneumothorax in supine patients, and allow clinicians to definitively address related issues before leaving the resuscitation area (10). Patients may still need a chest CT scan to evaluate other injuries, and CT imaging may occasionally detect a pneumothorax that was not visible on supine lateral radiographs. Moreover, it is sometimes difficult to lateralize the pneumothorax on the lateral film if there are not other indicators (rib fractures, stab wounds, gunshots) of which side has the injury. However, there is still utility of this rapid, easilyperformed and interpreted, low radiation study for improving our detection of pneumothorax in the ED.
Edward S. Cotner, MD Olive View/UCLA Emergency Medicine Residency Program Los Angeles, California doi:10.1016/j.jemermed.2005.03.003
REFERENCES 1. Henderson S, Shoenberger J. Anterior pneumothorax and a negative chest x-ray in trauma. J Emerg Med 2004;26:231–2. 2. Kane T, Nuttall M, Bowyer R, Patel V. Failure of detection of pneumothorax on initial chest radiograph. Emerg Med J 2002;19: 468 –9. 3. Collins J, Samra G. Failure of chest X-rays to diagnose pneumothoraces after blunt trauma. Anaesthesia 1998;53:774 – 8. 4. Bridges K, Welch G, Silver M, Schinco M, Esposito B. CT detection of pneumothorax in multiple trauma patients. J Emerg Med 1993;11:179 – 86. 5. Tocino I. Pneumothorax in the supine patient. Radiographics 1985; 5:557– 86. 6. Carr J, Reed J, Choplin R, Pope T, Case L. Plain and computed radiography for detecting experimentally induced pneumothorax in cadavers: implications for detection in patients. Radiology 1992; 183:193–9. 7. Glazer H, Anderson D, Wilson B, Molina P, Sagel S. Pneumothorax: apperance on lateral chest radiographs. Radiology 1989;173: 707–11. 8. Morgan R, Owens C, Collins C, Evans W, Hansell D. Detection of pneumothorax with lateral shoot-through digital radiography. Clin Radiol 1993;48:249 –52. 9. Hoffer F, Ablow R. The cross-table lateral view in neonatal pneumothorax. AJR Am J Roentgenol 1984;142:1283– 6. 10. Tocino I, Miller M, Fairfax W, Distribution of pneumothorax in the supine and semirecumbent critically ill adult. AJR Am J Roentgenol 1985;144:901–5.
e UPPER AIRWAY MASS MIMICKING NEAR-FATAL ASTHMA e To the Editor: We read with interest the article by Kokturk et al. (1) on subglottic mass mimicking near-fatal asthma. We would like to share our experience by describing a case of upper airway mass mimicking near-fatal asthma. A 62-year-old woman went to a hospital with wheezing, shortness of breath, and dry cough. She was diagnosed with bronchial asthma and her symptoms seemed to improve slightly after use of bronchodilators. One year later, however, she developed acute onset of severe respiratory distress and bloody sputum. A computed tomography (CT) scan of the neck and chest showed a tumor at the isthmus of the thyroid gland and an intratracheal mass having the same density as the tumor and obstructing almost the entire lumen at the level of the fifth cervical vertebra. The patient was referred to our hospital. On admission, she was critically ill, frightened, and tachypneic, using accessory respiratory muscles and
The Journal of Emergency Medicine
speaking in one-word sentences. The patient underwent bronchoscopy that showed a hemorrhagic mass almost completely obstructing the tracheal lumen. Using the scope, an endobronchial tube was placed without delay, but sufficient material was not obtained to be able to diagnose the mass pathologically. Thereafter, total thyroidectomy with sleeve resection of the cervical trachea was carried out. The tumor was successfully removed and histological examination revealed a papillary carcinoma of the thyroid. Now, 14 years after the operation, the patient remains well. Bronchial asthma is a common illness in society and often patients are labeled “asthmatic” without appropriate evaluation. Slowly growing upper airway tumors are often misdiagnosed and treated as bronchial asthma. The case report by Kokturk et al. (1) and our case emphasize the fact that not all wheezes are attributable to asthma. It is important to bear in mind that upper airway obstructions can lead to asthma-like
105
symptoms in which establishment of the correct diagnosis may be challenging. Gen Ohara, MD Hiroaki Satoh, MD Katsunori Kagohashi, MD Morio Ohtsuka, MD Kiyohisa Sekizawa, MD Division of Respiratory Medicine Institute of Clinical Medicine University of Tsukuba Tsukuba-city, Ibaraki, Japan doi:10.1016/j.jemermed.2005.03.005 REFERENCE 1. Kokturk N, Demir N, Kervan F, Dinc E, Koybasioglu A, Turktas H. A subglottic mass mimicking near-fatal asthma: a challenge of diagnosis. J Emerg Med 2004;26:57– 60.