Asian Cardiovasc Thorac Ann 2005;13:74-76
© 2005 Asia Publishing EXchange Ltd
Severe Tracheal Compression as a Late Complication of Plombage
Pradeep Narayan, FRCS,
Aftab Yunus, FRCS,
John A Morgan, FRCS,
Raimondo Ascione, MD
Department of Cardio-thoracic Surgery, Bristol Royal Infirmary, Bristol, UK
For reprint information contact: Raimondo Ascione, MD Tel: 44 11 7928 3145 Fax : 44 11 7929 9737 Email: R.Ascione{at}bristol.ac.uk, Department of Cardio-thoracic Surgery, Bristol Royal Infirmary, Bristol BS2 8HW, UK.
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ABSTRACT
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Prior to the antituberculous drugs era, plombage was commonly performed for the management of pulmonary tuberculosis. However, this procedure has been associated with a variety of early and late complications depending on the technique as well as the material used. We report a rare case of severe tracheal compression as a late complication of plombage and a review of the literature.
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INTRODUCTION
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A 72-year-old woman with a body mass index of 33.2 was referred to the chest clinic for an assessment of her symptoms as she had been complaining of progressively worsening shortness of breath for the last 12 months. Her exercise tolerance was limited to less than a hundred yards in the flat and she was extremely wheezy in the mornings. Even though she was never proven to be asthmatic, use of salbutamol and beclomethasone inhalers had provided relief in the past but were minimally helpful at the time of presentation. More importantly, she was experiencing severe stridor associated with rapid desaturation over the last 2 to 4 weeks. Past respiratory history included tuberculosis for which she was treated in 1963 with a paraffin plombage. She also had a history of ischemic cardiomyopathy, moderate renal impairment, and peripheral vascular disease (PVD).
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CASE REPORT
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A baseline chest radiograph showed the presence of a mass in the right upper and mid-zone extending into the mediastinum and causing critical tracheal stenosis (Figure 1
). Owing to the stridor and the appearance of the chest X-Ray, she was referred to us for further investigation and a possible insertion of a tracheal stent to ameliorate her symptoms. Upon further investigations, the FEV1 was 0.94 litres, and the peak flow was 87 litres·min–1. The flow volume loops suggested variable intra-thoracic major airway obstruction.
A contrast CT scan showed the presence of a large mass occupying the entire upper and mid-zone of the right chest, extending into the mediastinum and compressing the trachea. Complete assessment of the co-morbidities and a review of the methodology of the primary plombage procedure suggested the use of a stent unnecessary and carrying out a major procedure unsafe. The poor clinical conditions suggested a minimally invasive approach. The plombage was thus aspirated under local anesthesia with the help of a 16 g needle. The aspirate consisted of 600 mL of a thick brownish fluid. No pus cells or organisms were seen and no growth occurred on the culture on enriched media. The aspiration produced immediate relief of her symptoms and decompression of the tracheal compression. There was a significant improvement in her lung function tests and she did not require inhalers at the time of discharge. At 3 months follow-up she remained symptom free with a remarkably improved chest radiograph (Figure 2).
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DISCUSSION
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The epidemic spread of tuberculosis after World War II and the deficiency of appropriate antituberculous drugs led to a renaissance in surgical procedures such as plombage thoracoplasty, initiated in 1891 by Tuffier. The most common interventional approaches of the day were those offered by collapse therapy, consisting of artificial pneumothorax, phrenic paralysis, plombages placed extra pleurally, and pneumo-peritoneum.1
Collapse therapy was a daunting undertaking, demanding a high level of commitment, both from the patient and the therapist. Pneumo-peritoneum was a form of collapse therapy that was used for cavitary pulmonary tuberculosis. However, studies conclusively revealed that this provided no definite benefits and the procedure was soon abandoned.2 Artificial pneumothorax required frequent interventions, treatment frequently lasted for years, and ultimately, it could only be successfully maintained in 25% of patients.1 Various extra pleural plombage methods were soon developed and provided a better option for the surgical management of tuberculosis.
Plombage thoracoplasty has been used almost exclusively for the collapse treatment of pulmonary tuberculosis. It involved insertion of an inert, foreign substance in a space created beneath the rib cage, in order to achieve an extra pleural pneumothorax to collapse the tuberculous cavities in the upper lobes. The most common foreign substance used was paraffin; however, lucite spheres in a polyethylene bag, fibreglass, ping pong balls and resin filled acrylic balls have all been used.
Foreign body rejection and migration of plombe to the axilla, subpectoral or even supraclavicular region are complications commonly seen with the use of a wax plombe.3 Frank clinical infection of the plombe leading to empyema, breast abscess, life threatening hemoptysis, spinal paralysis, oil aspiration, pneumonia and bronchial fistulas have been reported together with malignant lymphomas as a result of prolonged exposure to the infected plombe and fatal mediastinal compression.4 Fluid collection is known to occur in the plombe5 and was indeed the mechanism in our case. However, the peculiarity of our case is the occurrence at 36 years post procedure, leading to a severe tracheal compression, an unreported complication of plombage.
As the complications related to previous thoracic plombage procedures vary, the management of these complications can be challenging. Fatal late complications of plombage have been reported in the past and it has been suggested that early ablation of plombage should be considered in order to prevent these complications.6 A number of therapeutic options have been attempted. Thoracotomy and removal of the plombe along with a single stage decortication has been performed. Thoracoplasty with transposition of pectoralis major, serratus anterior and latissimus dorsi muscle to fill the residual pleural space has also been attempted.7
However, procedure related deaths are not uncommon and age and co-morbidities must be taken into account when planning a form of treatment. Our patient presented with a rather serious list of co-morbidities, which included being elderly, poor lung function, ischemic cardiomyopathy, renal impairment and peripheral vascular disease. In a recent article, Weissberg concluded that there is no need for a routine removal of every plombe. He also suggested avoiding major surgery in these usually severely ill and debilitated patients, if possible, as the addition of a major operative risk would be of no obvious benefit to them. Decortication can be very tedious and time-consuming and thoracoplasty would further add to respiratory embarrassment.8
In our case the aspiration of the mass provided a simple yet very effective means of relieving the critical tracheal compression. While this leaves room for the re-accumulation of fluid, repeat aspiration is all that would be required. It also prevents any complications resulting from a thoracotomy and complications resulting out of a rupture of the plombe. This treatment provides optimum relief from a potentially life threatening tracheal obstruction without subjecting a rather elderly population to the mortality and morbidity associated with a major procedure.
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REFERENCES
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ABSTRACT
INTRODUCTION
