Multistage Approach for Tracheobronchomalacia Caused by a Chest Deformity in the Setting of Severe Scoliosis

An Analysis of Tracheostomy Complications in Pediatric Patients With Scoliosis

OBJECTIVES/HYPOTHESISAL

To analyze tracheostomy-related complications in pediatric patients with scoliosis.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review of all patients with tracheostomy and scoliosis was performed at a single institution. The charts were reviewed for variables including difficulties with tracheostomy tube changes, poor positioning of tube, abnormal appearance of trachea, and emergency room visits and admissions for complications. Decannulation rates were also identified.

RESULTS

About 102 patients met inclusion criteria, 96 (94.1%) had scoliosis involving the thoracic spine, and 4 had scoliosis involving the cervical spine; 13 (12.8%) patients had documented poor positioning on tracheoscopy; 31 patients (30.3%) had at least one emergency room visit or admission for complications, such as accidental decannulation or bleeding from the tracheostomy; 19 (18.6%) patients required at least one tube change due to poor positioning, with 7 (6.9%) requiring multiple changes; 18 (17.7%) had reported difficulties with home tube changes. Custom length tubes were required in 9 patients (8.8%). The level of scoliosis was not associated with any of these complications. Abnormalities of the trachea, such as tortuosity, obstructive granulomas, or tracheomalacia, were seen in 35 patients (34.3%) on bronchoscopy. Scoliosis repair was performed in 18 patients (17.65%), of which two achieved decannulation. Ten patients (9.8%) overall were decannulated.

CONCLUSION

A portion of patients with scoliosis who are tracheostomy-dependent have anatomical abnormalities of the trachea and poor positioning of the tracheostomy tube. Decannulation rates are also lower in this population compared to the literature. Further work is required to elucidate if scoliosis predisposes patients toward tracheostomy-related complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Suffocation due to Thoracic Deformity Caused by Acromegaly

A 61-year-old man with gigantism and acromegaly choked and fell into a coma. Immediate tracheal intubation resulted in a return of his consciousness. Enhanced computed tomography indicated that the trachea and left main bronchus were compressed by the thoracic spine and sternum. He required tracheotomy and positive end-expiratory pressure to maintain his pulmonary function. This is the first case of suffocation due to a thoracic deformity associated with acromegaly. Physicians should focus on clearing the tracheal airway using computed tomography to elucidate the anatomical relationship between the trachea and surrounding structures in acromegalic patients suffering from dyspnea.

Extrinsic bronchial obstruction caused by scoliosis

STUDY DESIGN

A case report.

OBJECTIVE

To emphasize the importance of monitoring the breathing capacity in patients with moderate to severe scoliosis, even in adulthood.

SUMMARY OF BACKGROUND DATA

Diseases that disturb the structure of the chest wall affect the function of the respiratory pump. Restrictive respiratory pattern is caused by severe scoliosis. However, scoliosis may provoke obstructive changes due to compression of the airways. It can be a direct compression because of imprinting of vertebral bodies, or an indirect one, due to rotation forces. METHODS.: We have collected data from the patients' clinical history and have reviewed similar published cases.

CASE PRESENTATION

a white female, with frequent respiratory tract infections during her childhood. She was diagnosed as having 55° right T5-T11 scoliosis. At age of 26, an increase of her pulmonary symptoms appeared with difficulty to expel mucus and medium efforts dyspnea. A computed axial tomographic scan showed T8 vertebral body pushing against the right intermediate bronchus. A bronchoscopy found a decrease in the bronchial area, with near contact between the walls. Lung function test: 41% forced vital capacity (FVC), 43% forced expiratory volume in 1 second (FEV1), and 91 FEV1/FVC1. The patient underwent surgical correction using rods and pedicle screws; she had improvement of symptoms, image tests, and pulmonary function (70% FVC, 71% FEV1, and 101 FEV1/FVC).

CONCLUSION

Increased frequency and severity of respiratory tract infections, difficulty in expelling mucus and dyspnea are warning signs of compromised airways. Spirometry tests and image tests such as computed axial tomography and bronchoscopy are essential for diagnosis. Surgical approach may be the treatment of choice.

A new technique for treatment of tracheal compression by the innominate artery: external reinforcement with autologous cartilage graft and muscle flap suspension

We report a new technique for treatment of tracheomalacia or tracheal compression caused by the innominate artery, utilized in two patients with neuromuscular disorders. Both cases developed a chest deformity in the setting of severe scoliosis. Computed chest tomography and fiberoptic bronchoscopy showed that the cervical trachea was compressed between the innominate artery and the cervical spine in the setting of deformity of the thoracic cavity. Both patients required prolonged mechanical ventilation prior to the operative procedure. To relieve compression by the innominate artery, the superior mediastinum was exposed by resection of part of the manubrium allowing a greater space, and external stenting of the cervical trachea with a reinforcing autologous cartilage graft and tracheopexy, as well as anterior suspension of the innominate artery with a sternohyoid muscle flap were carried out. Both patients were successfully weaned from prolonged mechanical ventilation. Resection of the manubrium sterni, tracheal stenting with rib segments and use of the strap muscle to elevate the innominate artery off of the trachea offer potential long-term release of airway obstruction.