Asian Cardiovasc Thorac Ann 1999;7:68-70
© 1999 Asia Publishing EXchange Pte Ltd
Traumatic Main Bronchial Disruption: Radiologic Evaluation and Surgical Management
Öztekin Oto, MD,
Ünal Açikel, MD,
Erdem Silistreli, MD,
Özalp Karabay, MD,
Egemen Tuzun, MD1,,
Ugur Gurgan, MD2,,
Hudai Catalyurek, MD,
Nejat Sariosmano
lu, MD
Department of Thoracic & Cardiovascular Surgery Dokuz Eylul Medical Faculty  zmir, Turkey
1 Department of Thoracic & Cardiovascular Surgery Celal Bayar Medical Faculty Manisa, Turkey
2 MEDIM Radiodiagnostic Center zmir, Turkey
|
|
For reprint information contact: Erdem Silistreli, MD Tel: 90 232 277 5867 Fax: 90 232 277 2165 email: silistre{at}cs.med.deu.edu.tr Mithatpasa Cad. No. 257/5, Balcova, zmir 35340, Turkey.
|
 |
Abstract
|
|---|
A 23-year-old female suffered right main bronchial transsection as a result of blunt chest trauma. The lesion was suspected at plain radiography and clearly shown on three-dimensional helical computed tomography imaging. Urgent primary repair was performed successfully. This technique of diagnosis with its three-dimensional viewing capability, can be helpful in defining the location and extent of various injuries.
|
Introduction
|
|---|
Tracheobronchial rupture is a serious injury occurring in approximately 1.5% of cases of major chest trauma.1 This rather infrequent type of disruption is often detected as episodical, even in large centers. The clinical picture is not uniform and the correct diagnosis may be delayed.
|
Case Report
|
|---|
Our patient was a 23-year-old female who was followed up in another center for 25 days without any intervention after a traffic accident. She had a trimalleolar fracture of the left ankle and a Colles fracture of the left forearm as well as fractures of the first and second right ribs and the first left rib. No subcutaneous emphysema or respiratory distress were documented in her initial examination. Chest radiographs were normal during the first 23 days after the trauma. During the next two days, respiratory distress developed and repeat chest radiographs showed pneumothorax with pulmonary atelectasis at the right side. Flexible bronchoscopy showed total obstruction by granulation tissue of the right main stem bronchus distal to the carina. Magnetic resonance imaging revealed the obstruction site with the atelectatic lung distally. Conventional computed axial tomography demonstrated neither the obstruction site nor the pulmonary parenchymal pathology.
Axial helical computed tomography (CT) images without contrast were obtained with 5-mm collimation and 1.2 pitch using a GE Sytec SRI (General Electric, Milwaukee, IL, USA). The 3-mm retro-reconstructed data were post-processed to form 3-dimensional images using multiplanar volume reconstruction and the surface-shaded display technique with GE Advantage Windows software (General Electric, Milwaukee, IL, USA). This diagnostic technique revealed an abrupt termination of the right main bronchial lumen 14 mm after the bifurcation as well as near total collapse of the right lung. The last finding was indicated from the lack of pulmonary tissue visible in the right hemithorax (Figure 1
). The abrupt termination of the right main bronchial lumen can be seen in Figure 2. The right main bronchial transsection was repaired through a right posterolateral thoracotomy using interrupted 4/0 polypropylene sutures. Postoperatively, the right lung could be totally expanded. Significant improvement was confirmed by chest radiograph, blood gas analysis, and pulmonary function tests. The postoperative 3-dimensional helical CT image of the healed lung is shown in Figure 3.
View larger version (150K):
[in this window]
[in a new window]
|
Figure 1. Preoperative image of the thorax with three-dimensional shaded-surface display. The abrupt termination of the right main bronchial lumen can be seen. The empty space in the right hemithorax is indirect evidence of the collapsed lung.
|
|
View larger version (113K):
[in this window]
[in a new window]
|
Figure 2. Using the multiplanar volume reconstruction technique, the termination of the right main bronchial lumen can be clearly seen.
|
|
View larger version (137K):
[in this window]
[in a new window]
|
Figure 3. Postoperative evaluation with the multiplanar volume reconstruction technique. The expanded right lung and patency of the right bronchial lumen can be seen.
|
|
|
Discussion
|
|---|
The pathogenesis of tracheobronchial rupture in blunt chest trauma can result from three mechanisms. The first is a decrease in the anteroposterior diameter of the thorax with widening of the transverse diameter. Secondly, when the trachea and major bronchi are crushed between the sternum and the vertebral column with the glottis closed, the sudden increase in intrabronchial pressure can lead to rupture. Thirdly, rapid deceleration may result in shearing forces at the areas of fixation, namely the carina and the cricoid cartilage.2 Clinical presentation with subcutaneous emphysema, dyspnea, sternal tenderness, pneumothorax, pneumomediastinum, hemoptysis, and rib or clavicle fractures should increase suspicion. Early recognition and repair of these injuries clearly decreases the morbidity and mortality. Primary bronchial anastomosis must be planned as the first choice.3,4
Radiologic signs are mostly nonspecific, with pneumo-thorax and pneumomediastinum being the most common.1,4 A high level of suspicion is required to make the diagnosis. Nearly all reports recommend that emergency bronchoscopy be carried out in patients with blunt chest trauma having suggestive clinical features to exclude this potentially treatable condition. Computed tomography can be helpful, however, it provides only indirect evidence.
Three-dimensional helical CT is the diagnostic technique of choice, with its capacity for noninvasive and prompt evaluation. Multiplanar and 3-dimensional reformatted images may be helpful, especially in cases where axial imaging alone is of limited usefulness.5 There was a striking difference between the results of the axial CT and 3D helical CT in our patient. These techniques have been reported to be particularly useful for evaluation of focal stenosis of the airways, as in our patient.5 In addition, these imaging modalities should also be considered in the follow-up of lesions treated by surgery or endoscopy in patients who do not require routine bronchoscopy.6 We did not perform bronchoscopic examination in our patient.
|
References
|
|---|
-
Huson H, Sais GJ, Amendola MA. Diagnosis of bronchial rupture with MR imaging. J Magn Reson Imaging 1993;3:919–20.[Medline]
-
Baumgartner F, Sheppard B, de Virgilio C, Esrig B, Harrier D, Nelson RJ. Tracheal and main bronchial disruptions after blunt chest trauma: presentation and management. Ann Thorac Surg 1990;50:569–74.[Abstract]
-
Çetin G, Koryak M, Özgen G. Künt toraks travmalari sonucunda olusan ana brons rüptürleri ve cerrahi tedavileri. Tüberkülöz ve Toraks 1974;22:243–8.
-
Wan YL, Tsai KT, Yeow KM, Tan CF, Wong HF. CT findings of bronchial transection. Am J Emerg Med 1997;15:176–7.[Medline]
-
Jardin MR, Remy J, Deschildre F, Artaud D, Ramon PH, Edme JL. Obstructive lesions of the central airways: evaluation by using spiral CT with multiplanar and three-dimensional reformations. Eur Radiol 1996;6:807–16.[Medline]
-
Lee KS, Yoon JH, Kim TK, Kim JS, Chung MP, Kwon OJ. Evaluation of tracheobronchial disease with helical CT with multiplanar and three-dimensional reconstruction: correlation with bronchoscopy. Scientific Exhibit 1997;17:555–70.
TOP
Abstract
Introduction
