British Journal of Radiology (2006) 79, 529-535
© 2006 British Institute of Radiology
doi: 10.1259/bjr/17839516
Deep tracheal laceration after balloon dilation for benign tracheobronchial stenosis: case reports of two patients
Y H Kim, MD1,
D J Sung, MD1,
S B Cho, MD1,
K B Chung, MD1,
S H Cha, MD1,
H S Park, MD2 and
J W Um, MD3
Departments of 1Radiology, 2Urology and 3Surgery, Korea University College of Medicine, Seoul, Korea
Correspondence: Ji Hoon Shin, MD, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap-2dong, Songpa-gu, Seoul 138-736, Korea.
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Abstract
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We report two cases of deep tracheal laceration in female patients after balloon dilation for benign tracheobronchial stenosis. Immediate post-procedure bronchoscopy and CT including 3D reconstructions showed deep lacerations in the posterior tracheal wall. Clinically, the patients' dyspnoea subsided and there has been no recurrence during follow-up after balloon dilation. On the follow-up 3D-reconstructed CT scans obtained 2 months and 8 months following balloon dilation, respectively, the lacerations had healed completely and there was considerable improvement in lumen size.
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Introduction
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Since Cohen et al [1] initially reported balloon dilation of tracheobronchial stenosis in 1984, endoscopically or fluoroscopically guided balloon dilation has become an accepted treatment for benign tracheobronchial stenosis [2–7]. The major anticipated advantages of balloon dilation are lower morbidity and mortality than those of corrective surgery or bougienage.
Although balloon dilation is safe and effective, excessive balloon inflation may theoretically lacerate or rupture the airway, thereby causing bleeding, pneumothorax, pneumomediastinum or mediastinitis. As far as we know, there is only one report [7] briefly describing superficial or deep lacerations of the tracheobronchial tree after balloon dilation for benign tracheobronchial strictures. However, there was neither a detailed description of the laceration nor information regarding the patients' detailed clinical outcomes.
We present two cases of deep tracheal laceration confirmed on post-procedure bronchoscopy and CT scans following balloon dilation for benign tracheobronchial stenosis, as well as the detailed clinical data.
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Case reports
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Case 1
A 31-year-old female complained of aggravated cough, dyspnoea, and a 3 kg weight loss over a 7 month period. She had a past history of pulmonary tuberculosis 10 years ago. Chest radiography was normal. However, bronchoscopy with biopsy and chest CT including three-dimensional (3D) reconstructions (Figure 1
) showed a 6 cm long tracheal fibrotic stenosis and a 1.5 cm long right main bronchial fibrotic stenosis, which was covered with whitish-yellow elevated lesions. The diameters of the narrowed segments of the trachea and right main bronchus were 6 mm and 2 mm, respectively, while those of the normal segment of the trachea and right main bronchus were 16 mm and 11 mm, respectively. A pulmonary function test (PFT) showed a forced expiratory volume in one second (FEV1) of 1.3 l (45%, predicted) and a forced vital capacity (FVC) of 2.0 l (54%, predicted).
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Figure 1. Case 1.(a) Anteroposterior and (b) lateral views of the three-dimensional (3D) reconstruction CT, obtained 4 days before balloon dilation, show a 6 cm long tracheal stenosis (arrowheads in (a) and (b)) from the mid-trachea to the carina and a 1.5 cm long right main bronchial stenosis (arrows in (a)).
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The detailed technique of balloon dilation is the same as described in the previous report [7]. We initially dilated the right main bronchial stenosis and subsequently the tracheal stenosis. A 6 mm diameter balloon catheter was used first for the severe right main bronchial stenosis in order to provide passage of the larger balloon catheter. Then the balloon (Boston Scientific/Medi-tech, Watertown, MA; 10 mm in diameter and 4 cm long for the bronchial stenosis, 18 mm in diameter and 10 cm long for the tracheal stenosis) was slowly inflated manually using a diluted water-soluble contrast medium until the waist formation in the inflated balloon catheter at the stricture segment disappeared. There was not much resistance during balloon inflation.
Immediately after balloon dilation, the patient complained of mild chest pain and expectorated some blood-tinged sputum. On bronchoscopy (not shown) obtained immediately after balloon dilation, a tracheal laceration was observed at the posterior tracheal wall. Its length and depth were estimated at approximately 5 cm and 8 mm, respectively, on bronchoscopy. For further evaluation of the extent of the laceration and possible associated complications, CT scanning was performed and revealed a deep, longitudinal laceration on the posterior tracheal wall with the pneumomediastinum (Figure 2). As a result of the tracheal laceration and separation of the tracheal wall at the tear point, the diameter of the trachea became widened. The patient's vital signs were stable, she was without fever or chills and there was no change in her haemoglobin level. Her chest pain and blood-tinged sputum disappeared within 24 h. Therefore, she was prescribed only oral antibiotics to prevent possible infection and was discharged from the hospital 5 days after the procedure.
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Figure 2. Case 1. Immediately after balloon dilation, the lumens of the stenoses appear to be widened on(a) the anteroposterior view of the 3D reconstruction CT. However, a long and deep laceration (arrowheads in (b) and (c)) on the posterior tracheal wall with pneumomediastinum (arrows in (c)) is well visualized on (b) the lateral view of the 3D reconstruction CT and (c) axial CT scan.
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On follow-up CT scans (Figure 3) obtained 8 months following balloon dilation, the deep laceration had completely healed and the widened tracheal lumen was maintained. Tests, also obtained 8 months following balloon dilation, showed an FEV1 of 1.8 l (63%, predicted) and an FVC of 3.3 l (89%, predicted); the FEV1 and FVC increased as much as 18% and 35%, respectively, compared with those of the predilation PFT. The patient has maintained her symptomatic improvement without recurrence for 10 months.
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Figure 3. Case 1.(a) Anteroposterior and (b) lateral views of the follow-up 3D reconstruction CT scans show marked improvement of the right main bronchial (arrows in (a)) and tracheal stenosis (arrowheads in (a)) without further visualization of the deep laceration on the posterior tracheal wall (arrowheads in (b)).
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Case 2
A 27-year-old woman had complained of respiratory difficulty for 3 months. She had a past history of tracheal intubation due to decreased mental ability by reason of diabetic ketoacidosis for 6 months. Bronchoscopy and CT (Figure 4) obtained 3 weeks before balloon dilation revealed two focal fibrotic stenoses in the mid and lower levels of the trachea. The diameters of the narrowed segments in the mid and lower levels of the trachea were 5 mm and 12 mm, respectively, while the diameter of the normal segment in the trachea was 16 mm. PFT's performed 1 week before balloon dilation were as follows: the FEV1 was 1.1 l (39%, predicted) and the FVC was 2.3 l (65%, predicted).
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Figure 4. Case 2. Anteroposterior view of the three-dimensional (3D) reconstruction CT obtained 3 weeks before balloon dilation, shows two focal stenoses (arrows) at the mid and lower levels of the trachea.
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Dilation was performed without much resistance, using an 8 cm long and 16 mm diameter balloon for the two focal tracheal stenoses. Immediately after balloon dilation, the patient complained of mild chest pain. On bronchoscopy and CT (Figure 5) obtained immediately after balloon dilation, a deep longitudinal laceration (4.5 cm in length, 1 cm in depth) was detected at the mid-level of the posterior tracheal wall. Her vital signs were stable without fever, and her chest pain disappeared within 24 h. She did not receive any further therapy except for preventative oral antibiotics.
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Figure 5. Case 2. Immediately after balloon dilation, a deep laceration(arrowheads) on the posterior tracheal wall is clearly visualized on the axial CT scan.
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On follow-up CT scans (Figure 6) obtained 2 months following balloon dilation, the deep laceration had nearly disappeared and the tracheal lumen was widened. Follow-up PFT, obtained 2 months after balloon dilation, showed an FEV1 of 1.9 l (69%, predicted) and an FVC of 2.3 l (65%, predicted); the FEV1 had increased as much as 30% compared with that of the pre-dilation PFT. The patient's symptoms were much improved and had not recurred for 5 months at the time of writing after balloon dilation.
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Figure 6. Case 2.(a) Anteroposterior view of 3D reconstruction and (b) axial scan of the follow-up CT show improvement of the two focal tracheal stenoses (arrows in (a)) and reveal a completely healed deep laceration on the posterior tracheal wall.
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Discussion
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Although expandable metallic stent deployment has been an effective and minimally invasive procedure for benign tracheobronchial stenosis and may overcome the problem of short-term recurrence after balloon dilation, stent placement has notable drawbacks, including migration, recurrence of stenosis from tissue hyperplasia, stent fracture and difficulty of stent removal [4, 7–10]. Therefore, balloon dilation is usually performed as the initial treatment for benign tracheobronchial stenosis because it is a safe and simple procedure [2–7]. However, several complications, such as bronchospasm or lung atelectasis after balloon dilation, have been reported by several authors [7, 11–13]. Furthermore, overdilation of the stenosis may cause tracheobronchial rupture similar to the rupture or bleeding reported for balloon dilation of the upper gastrointestinal tract [14–16]. Although the predominant fibrotic process can be successfully dilated and has a potentially successful clinical outcome [3, 6], there may be potential complications such as laceration or even free perforation of the tracheobronchial tree after sudden balloon dilation of fibrotic stenosis because of the hardness or stiffness of the fibrotic stenosis.
To the best of our knowledge, Lee et al [7] initially reported tracheal or bronchial laceration after balloon dilation, i.e. two cases of deep mucosal laceration and 15 cases of superficial mucosal laceration of the 59 patients treated with balloon dilation for benign tracheobronchial stenosis. In their report, most patients (45 of 59, 76%) had chronic fibrotic stenosis due to tuberculosis, and balloons for bronchial and tracheal stenosis were 6–12 mm and 14–20 mm in diameter, respectively. Their patients experienced tracheobronchial laceration (25%, 17/59) with relatively high frequency after balloon dilation, although the procedures were performed with caution. However, in Lee's report, the clinical outcome and follow-up data of the deep tracheal or bronchial laceration were not documented in detail. Interestingly, in our two cases the long and deep tracheal laceration disappeared completely during the follow-up period after balloon dilation. Lee et al [7] also briefly stated that two deep lacerations left no subsequent clinical sequelae. We assume that, if a deep laceration heals soon without much growth of granulation tissue, a good clinical outcome can be achieved after the deep tracheobronchial laceration because the lumen of the stenotic segment will be widened enough. Balloon dilation for congenital tracheal stenosis is another illustration of further proof to support our assumption that rupture of the complete cartilaginous rings by balloon dilation represents a prerequisite step for increasing the luminal diameter itself [17, 18].
As in our cases, even the deep and large tracheal laceration can be treated conservatively if patients show stable conditions and a minimal and asymptomatic pneumomediastinum. However, if patients present with acute respiratory distress secondary to a tracheal laceration, surgical or interventional treatment is indispensable [19]. Bronchoscopy can detect early tracheal laceration and determine the location. However, bronchoscopy may not offer sufficient information about anatomical location and morphology of deep tracheal laceration due to limited sight of view. In contrast, CT including 3D reconstructions can not only delineate the precise extent and morphology of the deep laceration, but also detect pneumomediastinum or mediastinal bleeding, which are important factors in deciding the treatment plan.
This investigation has disclosed a potential conflict; none of the other authors have identified a conflict of interest.
Received for publication February 17, 2005.
Revision received May 6, 2005.
Accepted for publication May 23, 2005.
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Abstract
Introduction
