Association of anesthetic and surgical risk factors with outcomes of initial diagnostic biopsies in a current cohort of children with anterior mediastinal masses

BackgroundDiagnostic biopsies of pediatric anterior mediastinal masses (AMMs) are high-risk procedures in which general anesthesia (GA) is traditionally avoided. However, awareness of historically recognized risk factors and corresponding perioperative management have improved over time and may now no longer strictly preclude the use of GA. Therefore, in this study, we examined the association of anesthetic and surgical risk factors and modalities with resulting procedural and survival outcomes in a current patient cohort.MethodsWe retrospectively reviewed charts of 35 children with AMMs who underwent initial diagnostic biopsies between January 2001 and August 2019, and determined tracheal compression and deviation from archival CT scans and procedural and disease outcomes.ResultsTwenty-three (65%) patients underwent GA while 12 (35%) received sedation. Among patients with available CT measurements, 13 of 25 (52%) had >50% anteroposterior tracheal diameter reduction. Patients with >50% anteroposterior tracheal compression received sedation more frequently (p=0.047) and were positioned upright (p=0.015) compared with patients with ≤50% compression, although 4 of 13 and 9 of 12, respectively, still received GA. Intraoperative adverse events (AEs) occurred in four (11.4%) patients: three received GA, and all were positioned supine or lateral. AEs were not associated with radiographic airway risk factors but were significantly associated with morphine and sevoflurane use (p<0.001) and with thoracoscopic biopsies (p=0.035). There were no on-table mortalities, but four delayed deaths occurred (three related to disease and one from late procedural complications).ConclusionsIn a current cohort of pediatric AMM biopsies, patients with >50% anteroposterior tracheal compression were more frequently managed with a conservative perioperative management strategy, though not completely excluding GA. The corresponding reduction in frequency of procedural AEs in this traditionally high-risk group suggests that increased awareness of procedural risk factors and appropriate risk-guided perioperative management choices may obviate the procedural mortality historically associated with pediatric AMM biopsies.

Case report: a step-wise management of concurrent presentation of congenital single lung and aberrant right subclavian artery in an infant girl

Introduction Congenital single lung (CSL) is a rare condition, and symptomatic patients often present with respiratory distress or recurrent respiratory infection due to mediastinal shift causing vascular or airway compression. Aberrant right subclavian artery (ARSA) is another rare congenital anomality that can lead to tracheal or esophageal compressions. There is only one other case of concurrent presentation of CSL and ARSA reported, which presented unique challenge in surgical management of our patient. Here we present a step-wise, multidisciplinary approach to manage symptomatic CSL and ARSA. Case presentation An infant girl with a prenatal diagnosis of CSL developed worsening stridor and several episodes of respiratory illnesses at 11 months old. Cross-sectional imaging and bronchoscopic evaluation showed moderate to severe distal tracheomalacia with anterior and posterior tracheal compression resulting from severe mediastinal rotation secondary to right-sided CSL. It was determined that her tracheal compression was mainly caused by her aortic arch wrapping around the trachea, with possible additional posterior compression of the esophagus by the ARSA. She first underwent intrathoracic tissue expander placement, which resulted in immediate improvement of tracheal compression. Two days later, she developed symptoms of dysphagia lusoria due to increased posterior compression of her esophagus by the ARSA. She underwent transposition of ARSA to the right common carotid with immediate resolution of dysphagia lusoria. As the patient grew, additional saline was added to the tissue expander due to recurrence in compressive symptoms. Conclusions Concurrent presentation of CSL and ARSA is extremely rare. Asymptomatic CSL and ARSA do not require surgical interventions. However, if symptomatic, it is crucial to involve a multidisciplinary team for surgical planning and to take a step-wise approach as we were able to recognize and address both tracheomalacia and dysphagia lusoria in our patient promptly.

Riedel's Thyroiditis Within an Elderly Patient Revealed by Tracheal Compression: a Case Report

Background : Riedel's thyroiditis (RT) is a rare fibrosclerotic disease that affects the thyroid gland and surrounding tissues. The etiology is unknown, and it rarely affects the elderly.Case Presentation : A 56-year-old man, with no particular medical history, was seen in consultation at the Surgery Department of the Treichville Teaching University Hospital for a painless swelling of the anterior base of the neck. Physical examination showed a patient with inspiratory dyspnea probably due to tracheal compression. The patient underwent a subtotal thyroidectomy because of the clinical symptomatology and the persistence of dyspnea. Macroscopically, the thyroid mass was well-encapsulated, weighed 80g, and measured 10 cm x 5 cm x 2 cm. After section, we observed whitish fibrous nodules associated with pinkish-brownish band. Histologically, the architecture of thyroid tissue was restructured by dense and diffuse collagenous fibrosis in which rare atrophic thyroid vesicles were found. The fibrous areas were infiltrated by inflammatory elements, including lymphocytes, plasmocytes, and eosinophilic polynuclear cells. No malignant cells were found. Masson's trichrome staining confirmed the fibrous nature of the thyroid tissue, which is essential for the certain diagnosis of Riedel's thyroiditis. There was no postoperative complication Conclusion : Riedel's thyroiditis is a rare disease that is difficult to diagnose preoperatively despite advances in imaging and fine needle cytology screening methods. Histological examination of the sample confirms the diagnosis of Riedel's thyroiditis. Thyroidectomy is indicated in patients with compression symptoms. Clinicians should suspect Riedel's thyroiditis in patients with a hard thyroid mass with compressive symptoms, despite its rarity.

Acute Airway Obstruction from Megaoesophagus Secondary to Achalasia Evaluated with Flexible Bronchoscope

A 94-year-old female presented to the emergency department with acute expiratory stridor. In the absence of an otorhinolaryngologist, an urgent laryngoscopy was performed using a flexible bronchoscope by an anaesthesiologist in the emergency department leading to a change in management. Subsequent radiographs confirmed severe tracheal compression from megaoesophagus secondary to achalasia as the cause of acute airway obstruction. Use of flexible bronchoscope as a diagnostic tool by an anaesthesiologist to evaluate a patient presenting with signs of acute airway obstruction may lead to a safer and more careful airway management planning. Suggestions are also made regarding establishment of emergency surgical airways when conventional approaches fail.