1/61. Retropharyngeal aberrant thymus.INTRODUCTION: Upper airway obstruction from a retropharyngeal mass requires urgent evaluation. In children, the differential diagnosis includes infection, trauma, neoplasm, and congenital abnormalities. Aberrant cervical thymic tissue, although occasionally observed on autopsy examination, is rarely clinically significant. We present the case of an infant with respiratory distress attributed to aberrant thymic tissue located in the retropharyngeal space. CASE: A 6-week-old infant was brought to the emergency department for evaluation of stridor associated with periodic episodes of cyanosis. Lateral neck radiograph revealed widening of the retropharyngeal soft tissues. The patient's symptoms did not improve with intravenous ampicillin-sulbactam. magnetic resonance imaging (MRI) performed on the seventh day of hospitalization revealed a retropharyngeal mass that extended to the carotid space. The mass was easily resected using an intraoral approach. Microscopic examination demonstrated thymic tissue. A normal thymus was also observed in the anterior mediastinum on MRI. The patient recovered uneventfully and had no further episodes of stridor or cyanosis. DISCUSSION: Aberrant cervical thymic tissue may be cystic or solid. Cystic cervical thymus is more common, and 6% of these patients present with symptoms of dyspnea or dysphagia. Aberrant solid cervical thymus usually presents as an asymptomatic anterior neck mass. This case is unusual in that solid thymic tissue was located in the retropharynx, a finding not previously reported in the English literature. Additionally, the patient presented in acute respiratory distress, and the diagnosis was confounded by the presence of mild laryngomalacia. In retrospect, our patient likely had symptoms of intermittent upper airway obstruction since birth. The acute respiratory distress at presentation was likely the result of laryngomalacia exacerbated by the presence of aberrant thymic tissue and a superimposed viral infection. Aberrantly located thymic tissue arises as a consequence of migrational defects during thymic embryogenesis. The thymus is a paired organ derived from the third and, to a lesser extent, fourth pharyngeal pouches. After its appearance during the sixth week of fetal life, it descends to a final position in the anterior mediastinum, adjacent to the parietal pericardium. Aberrant thymic tissue results when this tissue breaks free from the thymus as it migrates caudally. Therefore, aberrant thymic tissue may be found in any position along a line from the angle of the mandible to the sternal notch, and in the anterior mediastinum to the level of the diaphragm. In an autopsy study of 3236 children, abnormally positioned thymic tissue was found in 34 cases (1%). The aberrant thymus was most often located near the thyroid gland (n = 19 cases) but was also detected lower in the anterior neck (n = 6 cases), higher in the anterior neck (n = 8 cases), and at the left base of the skull (n = 1 case). The presence of thymic tissue in the retropharyngeal space in our patient is more unusual given the typical embryologic origin and descent of the thymus in the anterior neck to the mediastinum. Children with aberrant thymus may have associated anomalies. Twenty-four of 34 children (71%) with aberrant thymus detected at autopsy had features consistent with digeorge syndrome, and only 5 of the remaining 10 patients had a normal mediastinal thymus present. Our patient had normal serum calcium levels after excision and a mediastinal thymus was visualized on MRI. Biospy is required for diagnosis of cervical thymus and should also be considered to exclude other causes. MRI is helpful in delineating the presence, position, and extent of thymic tissue. Immunologic sequelae or recurrence after resection of an aberrant cervical thymus has not been reported.- - - - - - - - - - ranking = 1keywords = near (Clic here for more details about this article) |
2/61. Near-fatal airway obstruction after routine implant placement.Implants have gained tremendous popularity over the past two decades, and their placement in the interior edentulous mandible has become routine. A case of near-fatal airway obstruction secondary to sublingual bleeding and hematoma is presented. The complication, anatomy of the area, and previous literature are reviewed, as are precautions to implant placement and other surgical procedures near the floor of the mouth. Although placing dental implants is generally a benign procedure, practitioners must be prepared for potential complications and have a rehearsed plan of action for the treatment of emergent situations. The floor of the mouth contains branches of the submental and sublingual and mylohyoid arteries that may lead to life-threatening complications. This caution obviously extends to any dentoalveolar surgical procedures that concerns the floor of the mouth such as tori removal, extractions, and iatrogenic dental injuries.- - - - - - - - - - ranking = 2keywords = near (Clic here for more details about this article) |
3/61. Two cases of sjogren's syndrome with multiple bullae.Here, we report two rare female cases of sjogren's syndrome with multiple bullae, involving a 66- and a 51-year-old. Neither had any obvious pulmonary complaint. Chest radiographs and high-resolution CT (HRCT) scans showed interstitial linear and nodular opacities and multiple bullae. In the first case spirometry indicated an obstructive change judged by FEV1.0 and V50/V25. In both cases, histologic examination of the lung revealed thickening of alveolar septa and interstitial mononuclear cell infiltration. In the first case the bullae decreased in size with corticosteroid treatment. Airway narrowing due to peribronchiolar mononuclear cell infiltration causes a check-valve mechanism, which may lead to bullae formation. Although a rare occurrence, it is important to recognize that cystic or bullous lung disease can accompany sjogren's syndrome.- - - - - - - - - - ranking = 1keywords = near (Clic here for more details about this article) |
4/61. Unilateral expiratory airflow obstruction during forced exhalation.We present a case of unilateral airflow obstruction during forced exhalations. The patient presented with episodic dyspnea and wheezing, particularly when he lay in the right lateral decubitus position. spirometry revealed symmetric, marked reductions in forced expiratory volume in the first second and forced vital capacity values, while plethysmography demonstrated a near-normal total lung capacity. bronchoscopy revealed a polypoid lesion in the right main bronchus, of which biopsy specimens demonstrated adenoid cystic carcinoma. Following a right pneumonectomy, total lung capacity was markedly reduced; interestingly, however, spirometry was essentially unchanged. This case is an elegant illustration of the effects of respiratory maneuvers and body position on airway caliber.- - - - - - - - - - ranking = 1keywords = near (Clic here for more details about this article) |
5/61. 'Slide whistle' breath sounds: acoustical correlates of variable tracheal obstruction.We report a case of a man who developed severe shortness of breath and the finding of breath sounds that rose in frequency during inspiration and fell during expiration. These unusual sounds were caused by a spherical tumour arising from the main carina that nearly completely obstructed the distal trachea. The frequency variation disappeared after the removal of the mass. We evaluated this phenomenon using a modelling technique that we had previously developed to analyse the human airways as acoustical tubes. This analysis revealed that the acoustical conditions in the trachea were substantially modified by the presence of the solid mass as the trachea slightly dilated during inspiration, partially relieving the obstruction. Most of the anomalous characteristics of the breath sounds could be explained using this model. We conclude that a detailed understanding of the acoustic conditions of the airways allows correlation with anatomical and physiological conditions and may be of use in diagnosis or evaluation of the airways in health and disease.- - - - - - - - - - ranking = 1keywords = near (Clic here for more details about this article) |
6/61. Cine magnetic resonance imaging for evaluation of focal tracheomalacia: innominate artery compression syndrome.BACKGROUND: The contribution of an 'aberrant innominate artery' to respiratory distress syndromes has been a matter of debate nearly since the introduction of this concept. Recent advances in dynamic imaging are proving to be of value in assessing tracheal function in patients with respiratory distress. We therefore evaluated patients with innominate artery compression syndrome using the cine magnetic resonance imaging (CMRI) modality. OBJECTIVES: To apply the CMRI modality to evaluate patients with respiratory distress who exhibited tracheal compression at the level of the innominate artery. methods: A cohort of three patients in respiratory distress underwent bronchoscopy, followed by CMRI using a Siemens 1.5T Vision system. RESULTS: These three patients exhibited tracheal compression at the level of the innominate artery in agreement with their findings during bronchoscopy. All three exhibited dynamic tracheal compression that varied with the respiratory cycle. The degree of tracheal compromise was readily appreciated using the dynamic, real-time CMRI modality. Due to the severity of symptoms, the two children underwent innominate arteriopexy with complete resolution of their symptoms. CONCLUSIONS: CMRI provides extremely rapid acquisition of images, as well as integrated information regarding relationships of mediastinal structures. By providing functional imaging of tracheal patency during the respiratory cycle, CMRI may provide additional insight into innominate artery compression syndrome as more patients are evaluated.- - - - - - - - - - ranking = 1keywords = near (Clic here for more details about this article) |
7/61. Occlusion of a wire-reinforced endotracheal tube in an almost completely edentulous patient.Wire-reinforced endotracheal tubes have been advocated for use where endotracheal tube kinking is a risk. We report on a 79-year-old nearly edentulous male patient in a weakened state who managed to partially obstruct a wire-reinforced endotracheal tube, despite the presence of a soft bite block. The risk of kinking wire-reinforced endotracheal tubes is not mitigated simply because the patient is edentulous. Good monitoring, vigilance by providers and the use of a solid bite block remains critical in the care of these patients.- - - - - - - - - - ranking = 1keywords = near (Clic here for more details about this article) |
8/61. High dose rate brachytherapy for nonmalignant airway obstruction: new treatment option.STUDY OBJECTIVES: High dose rate (HDR) endobronchial brachytherapy is widely used as a palliative treatment for symptomatic airway obstruction by primary or secondary malignant tumors. We report on a successful use of HDR brachytherapy in patients with nonmalignant airway obstruction. DESIGN: Case series patients: Six patients received HDR brachytherapy for airway obstruction caused by granulation tissue around a metal stent placed for restoration of the airway patency for nonmalignant causes. In four patients, brachytherapy was performed following recurrent occlusion of the airway by granulation tissue formation; in two patients, it was done as a prophylactic procedure. INTERVENTION: HDR brachytherapy catheters were passed through the metal stents under direct fluoroscopic guidance. Simulation and computerized treatment planning were done, and a single dose of 10 Gy was administered using a brachytherapy remote afterloader with a (192)Ir source. The dose was prescribed to a distance of 1 cm from the center of the source, with a margin of 1 cm from the proximal and distal ends of the stent. RESULTS: At a median follow-up of 15 months, moderate granulation tissue formation was observed in only one patient; in four others, it was categorized as minimal, 5 to 30 months from the procedure. Restoration of the lumen was complete in four patients, near complete in one patient, and partial in one patient. In one patient, previously treated by external radiotherapy, local tissue necrosis was evident. CONCLUSION: HDR brachytherapy can be used safely for nonmalignant airway obstruction. Further studies including more patients and longer follow-up are needed.- - - - - - - - - - ranking = 1keywords = near (Clic here for more details about this article) |
9/61. A subglottic mass mimicking near-fatal asthma: a challenge of diagnosis.Upper airway obstruction due to a subglottic tumor can be easily misdiagnosed as bronchial asthma. We report on a 50-year-old woman who was ultimately diagnosed with subglottic tumor, but who presented with near-fatal asthma. According to her medical history she had been treated with high doses of prednisolone and bronchodilators for the past year for difficult asthma. The patient presented to the Emergency Department (ED) in severe respiratory distress. The chest X-ray study revealed bilateral hyperinflation. The flow-volume curve suggested a fixed airway obstruction. After performing a laryngoscopic examination, a subglottic mass was discovered and an urgent tracheotomy was performed. After the operation, all symptoms and respiratory distress disappeared. This case report emphasizes the fact that not all wheezes are attributable to asthma. Upper airway obstructions can lead to asthma-like symptoms in which establishment of the correct diagnosis may be challenging.- - - - - - - - - - ranking = 5keywords = near (Clic here for more details about this article) |
10/61. A near fatal case of corrosive burns from decomposed chloral hydrate administration.A case of corrosive burns to the face and upper airway from administration of chloral hydrate is presented. Events leading to the accident and dispensing of the drug are discussed.- - - - - - - - - - ranking = 4keywords = near (Clic here for more details about this article) |
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