Expanding wire stents in benign tracheobronchial disease: indications and complications

Prosthetic tracheobronchial stents provide palliative treatment for narrowed airways where surgical resection is inadvisable. Over a 1-year period, 28 Gianturco expanding wire stents were used in 15 patients for nonneoplastic indications: pure fibrous airway stenosis (6), fibroinflammatory stenosis (4), and tracheobronchial malacia (5). Insertion was technically straightforward. A satisfactory airway lumen with immediate improvement in ventilatory function was obtained in all patients. After insertion all patients had an irritation-type cough that either subsided spontaneously (10 patients) or was successfully suppressed with inhaled corticosteroid therapy (5 patients). The most common complication (12 patients) was granuloma formation leading to stent removal in 3 patients with fibroinflammatory stenosis. Other complications were dysphagia (1), suction catheter entrapment (1), and fatal massive hemoptysis (1). At a mean follow-up of 13 months (range, 3 to 19 months) all remaining stents are functioning well with no displacement or infection. Overall results were satisfactory in pure fibrous stenoses and tracheobronchial malacia but poor in the presence of inflammation. Tracheobronchial wire stents can be successfully used in selected patients.

Complete cartilage-ring tracheal stenosis associated with anomalous left pulmonary artery: the ring-sling complex

The persistent high mortality in infants with pulmonary artery "sling" (retrotracheal anomalous left pulmonary artery) is primarily due to the coexistence in such patients of long-segment tracheal stenosis due to complete cartilage rings. Five such patients are reported. Airway studies (by filtered high-kV radiography, bronchography, and/or CT) showed low carina, horizontal equal-length right and left mainstem bronchi, and long-segment tracheal stenosis. The length of the stenosis far exceeded the contact with the pulmonary sling. The suggested term "ring-sling complex" for such patients correctly places emphasis on detection of the tracheal malformation, which currently has no satisfactory surgical treatment.

Multiplanar and three-dimensional reconstruction techniques in CT: impact on chest diseases

The purpose of this review is to capture the current state-of-the art of the technical aspects of multiplanar and three-dimensional (3D) images and their thoracic applications. Planimetric and volumetric analysis resulting from volumetric data acquisitions obviates the limitations of segmented transverse images. Among the 3D reconstruction techniques currently available, the most recently introduced technique, i. e., volume rendering, has to be evaluated in comparison with 3D shaded surface display and maximum or minimum intensity projection. Slabs are useful in detecting and localizing micronodular or microtubular patterns and in analyzing mild forms of uneven attenuation of the lungs. Three-dimensional angiography is helpful in the pretherapeutic evaluation and posttreatment follow-up of pulmonary arteriovenous malformations, in the comprehension of the postoperative reorientation of the pulmonary vessels, in the surgical planning of pulmonary tumors, and in the diagnosis of marginated thrombi. The systemic supply to the lung and superior vena cava syndromes are also relevant to these techniques. In acquired or congenital tracheobronchial diseases including stenosis, extraluminal air and complex airway anatomy, multiplanar and 3D reformations have a complementary role to both transaxial images and endoscopy. New developments are also expected in various topics such as 3D conformal radiation therapy, planning of intraluminal bronchoscopic therapy, virtual endoscopy, and functional imaging of the bronchial tree. Miscellaneous clinical applications are promising in the analysis of diaphragmatic morphology and pathophysiology, in the volumetric quantification of the lung parenchyma, and in the vascular components of the thoracic outlet syndromes.

Three-dimensional helical CT of the tracheobronchial tree: evaluation of imaging protocols and assessment of suspected stenoses with bronchoscopic correlation

OBJECTIVE

To assess the accuracy of three-dimensional (3D) helical CT of normal airways, we evaluated different imaging protocols in test objects and patients. The clinical value of 3D helical CT was composed with bronchoscopy in patients with suspected stenoses, especially before and after endobronchial procedures.

SUBJECTS AND METHODS

Solid test objects--one of central airways and one of peripheral airways--were scanned and assessed for volume defects and stairstep artifacts. Fifty helical studies were performed in 36 patients. We evaluated these images for visualization of segmental bronchi; frequency of artifacts; and presence, localization, and degree of stenoses. Bronchoscopic correlation was available for 40 CT examinations. Follow-up 3D helical CT after endobronchial procedures was performed in nine patients.

RESULTS

In test objects, thin sections reduced volume artifacts. Overlapping sections mainly diminished stairstep artifacts. In vivo, overlapping sections were superior to contiguous sections for good visualization of the origin (96% versus 89%, p < .01) and of the course (75% versus 54%, p < .001) of segmental bronchi. Three-dimensional helical CT allowed us to assess accurately 36 of 36 central stenoses that were seen on bronchoscopy; however, on 3D helical CT, we missed two of three segmental stenoses. At bronchoscopy, 18 stenoses could not be passed, whereas 3D helical CT provided details for possible endobronchial procedures: length of stenosis, patency (12/18), and spatial orientation of distal bronchi. Follow-up 3D helical CT documented the efficacy of endobronchial treatment.

CONCLUSION

Three-dimensional helical CT based on thin overlapping sections accurately visualized the normal airways down to the origin of the segmental bronchi and central stenoses. When it complements bronchoscopy, 3D helical CT allows visualization beyond stenoses, supports planning of endobronchial procedures, and may even substitute for bronchoscopy after endobronchial procedures.

Volume rendering of the tracheobronchial tree: clinical evaluation of bronchographic images

PURPOSE

To evaluate the application of the volume-rendering technique to airway disease.

MATERIAL AND METHODS

Seventy-four spiral computed tomographic (CT) examination (1- to 5-mm section thickness; pitch, 1.7-20.0) were performed for known or suspected abnormality of the airways, including (a) benign tracheobronchial stenosis (group 1, n = 47), (b) complex airway lesions (group 2, n = 15), and (c) bronchiectasis (group 3, n - 12). Two radiologists independently compared overlapping transverse CT scans and volume-rendered bronchographic images for detection of airway abnormalities and identification of lesion morphology and extent, with bronchoscopic correlation.

RESULTS

Bronchographic image quality was graded as excellent (73%) or good (24%), whereas motion-related artifacts led to poor image quality in 3% of cases (trapezoid parameters included window width of -700 to -350 HU, triangular trapezoid shape, parenchymal opacification of 70%, unshaded algorithm). Compared with transverse CT scans, volume-rendered images (a) provided supplemental group 3, even, seven), (b) improved confidence in the interpretation of congenital airway abnormalities in six cases (8%) (all from group 2), and (c) corrected interpretive errors in four cases (5%) (group 1, two cases; group 2, two).

CONCLUSION

Volume-rendered images improved the recognition of mild changes in airway caliber and the understand of complex tracheobronchial anomalies.

Anaesthesia and tracheobronchial stenting for central airway obstruction in adults

In the last decade, stents suitable for the management of tracheobronchial stenoses and obstruction have evolved from bulky prostheses requiring tracheal resection to small devices that are self-expanding and can be inserted using fibreoptic techniques. The experience base for this review is more than 100 patients between 1989 and 2001 who have been anaesthetized for stent insertion. Early cases required rigid bronchoscopy for the routine of insertion. Anaesthetic techniques have evolved from those that were designed and developed for laser surgery in the central airways. The advent of modern devices now extends the variety of anaesthetic management techniques that can be used. But the original one, based on the requirement for use of a rigid bronchoscope, is best for dealing with complications and extracting problem stents. The most frequent complication of the processes of stent insertion has been respiratory failure because of carbon dioxide retention, consequent on obstruction with secretions in the area of the carina. The nature of central airway problems suggests that anaesthesia induction, management and teaching should not be founded on the conventional model-base of upper airway obstruction.

Management of substernal goiter

OBJECTIVE

To analyze the presentation, evaluation and treatment of patients with large substernal goiters, with emphasis on the radiographic evaluation and the results of treatment.

STUDY DESIGN

A retrospective chart review of 150 patients undergoing thyroidectomy at the Vanderbilt University Department of Otolaryngology-Head and Neck Surgery.

METHODS

Charts of patients undergoing thyroidectomy were reviewed. Those with substernal goiter, defined as a major portion of the goiter within the mediastinum, were included in the study. When available, the radiographic studies were reviewed by a staff neuroradiologist.

RESULTS

Twenty-three patients (15.3%) presented with substernal extension of the goiter. Characteristics of these patients included mean age of 59 years, 78% female, symptoms of compression such as dyspnea, choking, and dysphagia (65%), hoarseness (43%), and previous thyroid surgery (30%). Seventeen percent were asymptomatic. Preoperative radiographs demonstrated tracheal compression (73%), tracheal deviation (77%), esophageal compression (27%), and major vessel displacement (50%). Histology revealed multinodular goiter (16/23, 70%), thyroiditis (3/23, 13%), and malignancy (4/23, 17%). The average size of the resected specimen in greatest dimension was 8.0 cm (range, 3.0-14.0 cm) and weighed 148 g (range, 39-426 g). All were successfully approached through a transcervical incision without the need for sternotomy, and total thyroidectomy was performed in 83% of the cases. No major complications have been documented, and no evidence of tracheomalacia was encountered.

CONCLUSION

Despite the large size of these goiters and the significant involvement of the major mediastinal structures, all were approached through the transcervical incision. Further, despite significant tracheal involvement, there were no cases of tracheomalacia or major complications. For intraoperative planning, the authors advocate the routine use of preoperative computed tomography scanning.

Vascular anomalies and tracheoesophageal compression: a single institution's 25-year experience

BACKGROUND

Vascular rings are uncommon anomalies in which preferred strategies for diagnosis and treatment may vary among institutions. In this report, we offer a description of our approach and a review of our 25-year experience.

METHODS

A retrospective review was conducted of all pediatric patients with symptomatic tracheoesophageal compression secondary to anomalies of the aortic arch and great vessels diagnosed from 1974 to 2000.

RESULTS

Thirty-one patients (38%) of eighty-two patients (mean age, 1.7 years), were identified with double aortic arch, 22 patients (27%) with right arch left ligamentum, and 20 patients (24%) with innominate artery compression. Our diagnostic approach emphasized barium esophagram, along with echocardiography. This regimen was found to be reliable for all cases except those with innominate artery compression for which bronchoscopy was preferred, and except those with pulmonary artery sling for which computed tomography or magnetic resonance imaging, in addition to bronchoscopy, were preferred. Left thoracotomy was the most common operative approach (70 of 82; 85%). Ten patients (12%) had associated heart anomalies, and 6 (7%) patients underwent repair. Complications occurred in 9 (11%) patients and led to death in 3 (4%) patients.

CONCLUSIONS

In our practice, barium swallow and echocardiography are sufficient in diagnosing and planning the operative strategy in the majority of cases, with notable exceptions. Definitive intraoperative delineation of arch anatomy minimizes the risk of misdiagnosis or inadequate treatment.

New frontiers in CT imaging of airway disease

Combining helical volumetric CT acquisition and thin-slice thickness during breath hold provides an accurate assessment of both focal and diffuse airway diseases. With multiple detector rows, compared with single-slice helical CT, multislice CT can cover a greater volume, during a simple breath hold, and with better longitudinal and in-plane spatial resolution and improved temporal resolution. The result in data set allows the generation of superior multiplanar and 3D images of the airways, including those obtained from techniques developed specifically for airway imaging, such as virtual bronchography and virtual bronchoscopy. Complementary CT evaluation at suspended or continuous full expiration is mandatory to detect air trapping that is a key finding for depicting an obstruction on the small airways. Indications for CT evaluation of the airways include: (a) detection of endobronchial lesions in patients with an unexplained hemoptysis; (b) evaluation of extent of tracheobronchial stenosis for planning treatment and follow-up; (c) detection of congenital airway anomalies revealed by hemoptysis or recurrent infection; (d) detection of postinfectious or postoperative airway fistula or dehiscence; and (e) diagnosis and assessment of extent of bronchiectasis and small airway disease. Improvement in image analysis technique and the use of spirometrically control of lung volume acquisition have made possible accurate and reproducible quantitative assessment of airway wall and lumen areas and lung density. This contributes to better insights in physiopathology of obstructive lung disease, particularly in chronic obstructive pulmonary disease and asthma.

Stenosis of the central airways: evaluation by using helical CT with multiplanar reconstructions

PURPOSE

To assess the accuracy of helical computed tomography (CT) with multiplanar reconstructions (MPRs) in the evaluation of stenoses of the central airways.

MATERIALS AND METHODS

Thin-section axial CT and helical CT with MPRs were used to examine the central tracheobronchial tree for the presence of stenosis in 27 patients who underwent lung transplantation and 17 nontransplantation patients. The findings from these modalities were then compared with the findings obtained at conventional tomography and bronchoscopy, when available.

RESULTS

Axial CT alone was 91% accurate in depicting stenosis, CT with MPRs was 94% accurate, and conventional tomography was 89% accurate in the evaluation of bronchial anastomosis in transplant recipients. CT and CT scans with MPRs were each 91% accurate in depicting stenosis in nontransplantation patients; the single false-negative finding showed focal tracheomalacia at bronchoscopy.

CONCLUSION

CT with MPRs may be more accurate than thin-section axial CT in the demonstration of mild stenosis, the length of a stenosis, and horizontal webs.

Tracheobronchial Anomalies and Stenoses: Detection with Low-Dose Multidetector CT with Virtual Tracheobronchoscopy—Comparison with Flexible Tracheobronchoscopy

PURPOSE

To prospectively assess the sensitivity and specificity of low-dose multidetector computed tomography (CT) with virtual tracheobronchoscopy (VT) for evaluation of suspected airway stenoses and/or abnormalities by using flexible tracheobronchoscopy (FT) as the reference standard.

MATERIALS AND METHODS

The study was approved by the local ethics committee; parental consent was obtained. Forty-five patients with clinically and/or radiographically suspected tracheobronchial stenosis and/or anomaly underwent FT and contrast material-enhanced single-phase multidetector CT with VT. CT was performed with an age- and weight-adjusted low-dose protocol: 120 or 80 kV; 120 or 60 mA; collimation, 1.5 or 0.75 mm; gantry rotation, 0.5 second. Mean effective dose was calculated for all examinations. Postprocessing was performed with surface rendering of VT images and multiplanar reformations. CT images were analyzed in consensus by two radiologists who were blinded to FT results. Statistical analysis was performed with 2 x 2 contingency tables; 95% confidence intervals (CIs) were calculated with the Blyth-Still-Casella procedure.

RESULTS

Mean patient age was 4.4 years (range, 2 months to 16 years; 53% male patients). Tracheobronchial narrowing and/or abnormality were depicted at FT in 38 of 45 patients. In 33 of 38 patients, multidetector CT with VT depicted a tracheobronchial narrowing and/or anomaly. In 10 of 38 patients, tracheobronchial stenosis was induced by vascular anomalies. Five patients with normal findings at multidetector CT with VT had tracheobronchomalacia with inspiratory airway stenosis at FT. Sensitivity and specificity of CT with VT were 86.8% (95% CI: 73.3%, 94.7%) and 85.7% (95% CI: 44.6%, 99.3%), respectively. Positive and negative predictive values were 97.1% (95% CI: 84.9%, 99.9%) and 54.5% (95% CI: 25.0%, 80.0%), respectively. Overall accuracy was 86.7% (95% CI: 74.3%, 94.0%). Mean effective dose was 1.1 mSv (range, 0.5-1.8 mSv).

CONCLUSION

Multidetector CT with VT with a low-dose protocol had high sensitivity and specificity for depiction of tracheobronchial narrowings and/or anomalies. However, tracheal narrowing due to tracheobronchomalacia was difficult to diagnose at single-phase multidetector CT with VT.

Grading Airway Stenosis Down to the Segmental Level Using Virtual Bronchoscopy

OBJECTIVE

To assess the sensitivity of noninvasive virtual bronchoscopy based on multirow detector CT scanning in detecting and grading central and segmental airway stenosis using flexible bronchoscopic findings as the reference standard.

MATERIALS AND METHODS

In a blinded controlled trial, multirow detector CT virtual bronchoscopy and flexible bronchoscopy were used to search for and grade airway stenosis in 20 patients. CT scan data were obtained with a multirow detector CT scanner using 4 x 1 mm collimation. Flexible bronchoscopy findings were graded by a pulmonologist and served as the reference standard for 176 central airway regions (ie, trachea, main bronchi, and lobar bronchi) and 302 segmental airway regions. The extent of airway narrowing was categorized as grade 0 (no narrowing), grade 1 (< 50%), or grade 2 (> or =50%).

RESULTS

Flexible bronchoscopy revealed 30 stenoses in the central airways and 10 in the segmental airways. Virtual bronchoscopy detected 32 stenoses in the central airways (sensitivity, 90.0%; specificity, 96.6%; accuracy, 95.5%) and 22 in the segmental airways (sensitivity, 90.0%; specificity, 95.6%; accuracy, 95.5%). The number of false-positive findings was higher in the segmental airways (13 false-positive findings) than in the central airways (5 false-positive findings), which caused a lower positive predictive value for the segmental airways (40.9%) than for the central airways (84.4%). Flexible and virtual bronchoscopic gradings correlated better for central airway stenosis (r = 0.87) than for segmental airway stenosis (r = 0.61).

CONCLUSION

Although a high sensitivity was found for the detection of both central and segmental airway stenosis, the number of false-positive findings was higher for segmental airways. However, noninvasive multirow detector CT virtual bronchoscopy enables high-resolution endoluminal imaging of the airways down to the segmental bronchi.

Multidetector CT virtual bronchoscopy to grade tracheobronchial stenosis

OBJECTIVE

The purpose of this study was to compare the efficacy of noninvasive multidetector CT (virtual bronchoscopic images, axial CT slices, coronal reformatted images, and sagittal reformatted images) in depicting and allowing accurate grading of tracheobronchial stenosis with that of flexible bronchoscopy.

MATERIALS AND METHODS

Multidetector CT and flexible bronchoscopy were used to examine 200 bronchial sections obtained from 20 patients (15 patients with bronchial carcinoma and five without central airways disease). Multidetector CT was performed using the following parameters: collimation, 4 x 2 mm, pitch, 1.375; and reconstruction intervals, 2 mm. Postprocessing was performed using surface rendering and multiplanar reformatted images. CT images were independently interpreted by two radiologists. The tracheobronchial stenoses revealed on flexible bronchoscopy were graded by a pulmonologist.

RESULTS

Virtual bronchoscopic findings, axial CT scans, and multiplanar reformatted images were highly accurate (98% accuracy for virtual bronchoscopic images, 96% for axial slices and coronal reformatted images, and 96.5% for sagittal reformatted images) in revealing tracheobronchial stenosis. In allowing accurate grading of tracheobronchial stenosis, images from virtual bronchoscopy correlated closely (r = 0.91) with those of flexible bronchoscopy. Because use of virtual bronchoscopic images reduced the overestimation of stenosis, these images allowed better assessment of stenosis than did axial CT slices (r = 0.84) or multiplanar reformatted images (r = 0.84) alone.

CONCLUSION

Multidetector CT virtual bronchoscopy is a reliable noninvasive method that allows accurate grading of tracheobronchial stenosis. However, it should be combined with the interpretation of axial CT images and multiplanar reformatted images for evaluation of surrounding structures and optimal spatial orientation.

Computed tomography of the trachea: normal and abnormal

The trachea was investigated by means of computed tomography (CT) in 50 patients without tracheal or mediastinal abnormalities and in 39 patients with various diseases of the trachea. The variations in the normal CT appearances of the trachea and surrounding structures are described. CT did not provide additional information in the detection or characterization of tracheal stenosis beyond that obtained from more conventional studies, including tomography and positive-contrast tracheography. In patients with a saber-sheath trachea, CT demonstrated the abnormal configuration of the tracheal cartilages and abnormal collapse of the trachea on forced expiration. In patients with primary or secondary neoplasms involving the trachea, CT was most accurate in defining the intraluminal presence of tumor, the degree of airway compression, and the extratracheal extension of tumor. CT can be of value in determining the resectability of primary tracheal neoplasms and the planning of radiation therapy in metastatic lesions to the trachea and surrounding mediastinum.

Clinical evaluation of a new bifurcated dynamic airway stent: a 5-year experience with 135 patients

The Dynamic stent, a bifurcated airway prosthesis facilitating coughing, was clinically evaluated. The stents were inserted bronchoscopically in 135 patients (84 male, 51 female, age 12-90 years, mean 59 years) suffering from compression stenoses, strictures or malacias of the central airways, or tracheo-esophageal fistulas. Extrinsic compression from malignant and semi-malignant tumors was the leading indication for stenting (47.4%), followed by esophago-airway fistulas (22.2%) and post-intubation stenoses (14%). Stent insertion turned out to be very easy and could be performed without complications. The Dynamic stent was well tolerated and gave immediate relief of dyspnea in most cases. Follow-up data, three months after the last implantation revealed that at least 24 patients were still alive with a stent in place and free of complaints. In 27 cases, the stent had been removed after response to treatment. One of these patients received a second in order to seal a fistula, two months after removal of the first one. 85 patients, 79 with malignant, 6 with non-malignant diseases had died, with a mean survival time of 123 days (0 to 611 days). Complications directly attributable to the stent were rare. Two patients who had received the stent to counteract severe tracheal compression from aortic abnormalities died from arrosion and hemoptysis. There were no other severe complications. Cephalad migration occurred in 4/136 inserted stents. The Dynamic stent can be considered feasible, effective, and comparitively safe.

Laryngotracheal obstruction complicating tracheostomy or endotracheal intubation with assisted respiration. A critical review

Images

Central airway stenoses: preliminary results of spiral-CT-generated virtual bronchoscopy simulations in 29 patients

The purpose of this study was to determine the feasibility of using virtual bronchoscopy simulations to depict stenoses of the tracheobronchial tree. Virtual bronchoscopy simulations, based on ray casting, were applied to spiral-CT data sets of 29 patients presenting 41 stenoses of the central airways, proved with fiberoptic bronchoscopy. Simulations of the inner walls of the airways were of good quality in 27 of 29 patients. Airway stenoses were depicted in 39 of 41 cases. Evaluation of the length of stenoses and surrounding tissues required simultaneous display of multiplanar reformations. Virtual bronchoscopy provides a valuable road map for bronchoscopy, in an image format familiar to bronchoscopists.

Tracheal wire stent complications in malacia: implications of position and design

BACKGROUND

Although expandable endoluminal wire stents that can be incorporated into body tissues are very attractive for use in the airway, disease-related factors that can lead to stent failure have received little attention in the literature.

METHODS

The cases of all 4 patients who underwent insertion of one or more Gianturco stents into the trachea, main bronchi, or both for tracheobronchial malacia in our institution were reviewed.

RESULTS

All three tracheal stents required removal for stent-related complications within the first 6 months. Complications included metallic strut fracture and unraveling or breakage of the encircling nylon suture leading to progressively bizarre and widening radiographic configurations suggesting imminent airway perforation. One of the six bronchial stents disrupted 10 months after insertion.

CONCLUSIONS

Our findings suggest relatively less dynamic, repetitive bending wire stress in the bronchus (and likewise strictured trachea) compared with the malacic trachea. Although Gianturco stents are easily placed and give excellent functional results, we recommend against their use in the trachea for tracheal malacia. The bronchial position may be reasonably safe.

CT virtual bronchoscopy of the central airways in patients with Wegener's granulomatosis

OBJECTIVES

To compare CT virtual bronchoscopy (VB) to CT alone and to conventional bronchoscopy for evaluation of central airway stenoses in patients with Wegener's granulomatosis.

DESIGN

Prospective observer study, in which 18 thin-section helical CT scans of the trachea and bronchi of 11 patients with Wegener's granulomatosis were obtained. VB was performed using surface rendering and was evaluated by one bronchoscopist and one radiologist in a blinded fashion. Bronchoscopic correlation within an average of 1.8 days of CT was available.

MEASUREMENTS AND RESULTS

VB displayed 188 of 198 bronchi (95%). Thirty-two of 40 stenoses (80%) were detected by VB by at least one of two physicians (double reading), and 22 of 40 stenoses (55%) were detected by a third physician reading only the CT.

CONCLUSIONS

VB depicts bronchi to the segmental level and detects the majority of central airway stenoses in patients with Wegener's granulomatosis. A team approach is useful to attain optimal clinical benefit from VB for these patients.

Tracheal involvement in Wegener's granulomatosis: evaluation using spiral CT

OBJECTIVE

To describe the computed tomography (CT) appearances of tracheal stenosis in Wegener's granulomatosis (WG) and to assess the additional value of reformatted images.

PATIENTS AND METHODS

Ten patients with tracheal involvement by WG were assessed with spiral CT and both coronal and three-dimensional surface shaded images were generated. Fibreoptic bronchoscopy was also performed in all patients.

RESULTS

Ninety per cent of lesions were situated in the subglottic region. In all cases there was circumferential mucosal thickening, in nine cases extending over a relatively short distance (mean 2.4 cm). The degree of narrowing of the axial luminal diameter ranged from 23% to 100%. In three patients there was contiguous involvement of the vocal cords evident on CT, two further cases with mild vocal cord inflammation were identified bronchoscopically. Other CT findings included mucosal irregularity and ulceration (50%), and involvement of the tracheal cartilages (20%).

CONCLUSION

Wegener's granulomatosis may involve the trachea with resultant stenosis. Spiral CT is an easily performed, non-invasive technique which provides accurate assessment of tracheal lesions and is complementary to bronchoscopy. The main additional advantage of coronal reformatted images was our added confidence in defining the upper and lower limits of lesions and in the evaluation of vocal cord involvement.

Outcomes of Tracheobronchial Stent Placement for Benign Disease

PURPOSE

To retrospectively determine long-term outcomes in patients who have undergone tracheobronchial stent placement for benign diseases.

MATERIALS AND METHODS

Institutional Review Board approval was obtained for this retrospective HIPAA-compliant study, with waiver of informed consent. Forty patients (22 female, 18 male; mean age, 52.0 years) who were treated with metallic airway stents for benign stenosis were identified from an interventional radiology database. Causes of airway stenosis included transplant stricture (n = 13), tracheal tube injury (n = 10), inflammation (n = 6), tracheobronchomalacia (n = 4), infection (n = 3), and extrinsic compression (n = 4). Follow-up, which ranged from 6 to 2473 days, was performed by means of chart review for deceased patients and by means of clinical visit or telephone interview for surviving patients. Survival, primary patency, and assisted patency were estimated by using the Kaplan-Meier product limits method.

RESULTS

Initial technical success was achieved in all cases. Symptomatic improvement was present in 39 of 40 cases. At review, 15 patients were alive and had clinical improvement, 18 had died of comorbid causes, one had died of uncertain causes, three had undergone subsequent airway surgery, two had undergone airway stent retrieval, and one was lost to follow-up. Survival at 1, 2, 3, 4, 5, and 6 years was 79%, 76%, 51%, 47%, 38%, and 23%, respectively. Loss of primary patency was most rapid during the 1st year. With repeat intervention, assisted patency was 90% at 6.8 years.

CONCLUSION

Attrition of tracheobronchial stent patency is most rapid during the 1st year, and a high rate of long-term patency can be achieved with secondary interventions. Metallic airway stents are well-tolerated and useful adjuncts for management of select benign tracheobronchial stenoses.

Metallic tracheal stents: complications associated with long-term use in the upper airway

The use of metallic airway stents for the treatment of benign airway stenosis is increasingly advocated; however, the long-term safety and efficacy of these devices has not been established. Three case studies involving late but significant proximal tracheal stent complications are reported: 1 related to proximal mechanical stent failure and 2 related to obstructing granulation tissue and stenosis at the proximal stent orifice. Placement of these stents in close proximity to the cricotracheal junction is thought to be primarily responsible for these complications as a result of the excess shearing forces created at the stent-mucosal interface by the differential motion of the stent relative to the rigid subglottic airway and the more distensible trachea. Although the use of metallic stents remains appropriate in cases in which there is a defined and relatively short-term end point for treatment, caution is urged in using them in the proximal trachea for long-term management of benign airway disease.

Ectopic thyroid

Primary mediastinal ectopic goiters are very rare. We report a case in which an ectopic goiter with blood supply from the thoracic vessels necessitated a transternal approach for removal, resulting in a favorable outcome.