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PubMed1991

Rupture of the thoracic trachea following blunt trauma: diagnosis by CAT scan.

A case of isolated rupture of the thoracic trachea due to blunt trauma in a 4-year-old child is presented. The rarity of this injury and its initial presentation as massive subcutaneous emphysema and bilateral pneumothoraces warrant its description. This child was diagnosed as having a tracheal injury by computed tomography scan. The diagnosis was confirmed at bronchoscopy and was successfully treated by thoracotomy and primary closure of a 3-cm rent in the membranous portion of the trachea. There was difficulty with intraoperative ventilation due to the large air leak through the tracheal tear. This was controlled by intermittent tamponade of the defect with sequential closure. Postoperatively, the child did well and was discharged on the sixth postoperative day. Rigid bronchoscopy done 2 months later showed no abnormality. This case demonstrates that computed tomography is helpful in the diagnosis of tracheal injuries. The treatment may require early operative intervention and closure of the defect.

Child, Preschool↗
PubMed1984

Complications of tracheostomies in neurosurgical patients.

The records of the neurosurgical patients with tracheostomies who were treated at the University of Mississippi Medical Center during the past 5 years were reviewed. Of the 84 such patients, 45% had posttracheostomy complications, including pneumonitis, pneumothorax, pneumomediastinum, infected stoma, subcutaneous emphysema, tracheal stenosis, aspiration, swallowing dysfunction, and tracheoarterial fistula. Reported complications related to prolonged nasotracheal intubation, the alternative to tracheostomy, are reviewed. These complications appear to be less frequent and less serious than those of tracheostomy, in the authors' experience as well as in the reports of others. It is concluded that in neurosurgical patients, tracheostomy is not a benign procedure. Unless a specific indication for tracheostomy exists, consideration should be given to the use of prolonged nasotracheal intubation for airway maintenance.

Adolescent↗
PubMed1979

Pneumomediastinum as a complication of asthma in teenage and young adult patients.

The characteristics of 11 patients (age range, 13 to 31 yr) with asthma complicated by pneumomediastinum are presented. Nine of 11 patients were male. Cough and chest pain were prominent symptoms in the affected individuals. Subcutaneous emphysema was noted in all but 1 patient who presented with an unusual radiographic finding: a radiolucent rim surrounding the pulmonary artery. Hamman's sign was detected in 7 patients. None of the patients required specific therapy for pneumomediastinum. The pathophysiology of pneumomediastinum was reviewed.

Adolescent↗
PubMed1994

Aspirated foreign bodies in the respiratory tract of children: eleven years experience with 127 patients.

During 10 years, 127 children were admitted to the pediatric ward because of aspiration of foreign bodies (0.56% of all admissions). Eighty-one percent of the children were under 3 years of age. One hundred and one children (80%) had a positive history of foreign body aspiration. Vegetable substances, particularly peanuts and grains, were the commonest type of foreign body removed. Clinical signs and radiological studies were, in most children, pathognomonic, but sometimes not conclusive. Chest X-rays were normal in 18%; fluoroscopy was diagnostic in 92%. Rigid bronchoscopy and subsequent removal of the foreign body was the treatment instituted. Pneumonia (the commonest complication) developed before and after bronchoscopy in 28% of the children. Pneumomediastinum and subcutaneous emphysema were present on admission in 2 children. Cardiac arrhythmias, bronchospasm, and cardiac arrest were recorded during bronchoscopy. Bronchiectasis developed in one, and persistent intractable pneumonia, requiring lobectomy, developed in another patient. One death occurred.

Bronchi↗
PubMedDate not supplied

Pharyngoesophageal intubation injuries: three case reports.

The hypopharynx and cervical esophagus are particularly vulnerable to intubation trauma. Contributing factors include hasty intubation by inexperienced personnel; the use of curved, beveled endotracheal tubes containing stylets; malpositioning of the head, and the application of cricoid pressure. Iatrogenic pharyngoesophageal perforations may go unsuspected until characteristic signs and symptoms are recognized. These include cervical pain, fever, dysphagia, leukocytosis, subcutaneous emphysema, and pneumomediastinum. We present three cases that illustrate important points in recognizing, evaluating, and treating pharyngoesophageal perforations. The third case presents a chronic cervical esophageal perforation with secondary pseudodiverticulum, requiring resection of the pseudodiverticulum and a primary sternocleidomastoid muscle flap repair of the cervical esophageal defect. To our knowledge, this technique has not previously been reported.

Adult↗
PubMed1990

An unusual case of fatal accidental paraquat poisoning.

Paraquat, a useful contact herbicide is now used in over 130 countries of the world, including Sri Lanka. The number of cases of accidental poisoning reported with paraquat is small, relative to instances of suicide. When a clear history is not available, accidental paraquat poisoning is sometimes difficult to diagnose. A 9-year-old boy was admitted to a peripheral hospital with a history of diarrhoea and vomiting. He later developed abdominal pain, subcutaneous emphysema and difficulty in breathing. Following transfer to a district hospital and then to a teaching hospital, poisoning with paraquat was suspected only on day 11 of the illness. On persistent questioning, on day 13 of the illness the child remembered that the day prior to the onset of illness, on his way from a shop, he felt thirsty and having found an empty bottle of Gramoxone (paraquat) on the wayside he used it to drink water from a water tank. The child died on day 17 and the histology of the lung showed typical changes of paraquat poisoning. This tragic episode emphasises the need for proper disposal of empty containers of all poisonous substances.

Accidents↗
PubMed1995

Pneumomediastinum and pneumoretroperitoneum.

A 23-year-old man presented to the emergency department with extensive subcutaneous emphysema and severe dehydration after a prolonged self-imposed religious fast. Chest radiographs showed marked pneumomediastinum and pneumoretroperitoneum without pneumothorax. Patients are often admitted to the hospital for close observation when these findings are recognized, but this caution is generally unwarranted. This case illustrates the common occurrence of the usually benign entity of pneumomediastinum without pneumothorax.

Adult↗
PubMedDate not supplied

Barotrauma related to inhalational drug abuse.

Three patients are described who developed either pneumomediastinum or "clicking pneumothorax" after abusing illicit drugs. In recent years, patients presenting with pneumomediastinum after abusing cocaine have been frequently reported; these patients are most commonly young males with pleuritic chest pain. Seventy-three percent have detectable subcutaneous emphysema and fifty percent have a Hamman's sign. The pathophysiology, presenting features, and treatment of patients with barotrauma related to inhalational drug abuse are reviewed.

Administration, Inhalation↗
PubMedDate not supplied

The roentgenographic findings associated with air embolism in sport scuba divers.

Records on all patients with arterial gas embolism (AGE) presenting to UCSD from 1982-1989 and for whom chest radiographs were available were reviewed. Of the 31 patients, 13 roentgenograms (42%) showed evidence of pulmonary barotrauma demonstrated by pneumomediastinum (N = 8), subcutaneous emphysema (N = 3), pneumocardium (N = 2), pneumoperitoneum (N = 1), or pneumothorax (N = 1). Pneumopericardium was not seen. Sixteen (52%) of the 31 patients had pulmonary infiltrates. Radiographic evidence of barotrauma was on occasion subtle, and in four cases was overlooked. Evidence of barotrauma (i.e., extra-alveolar air) was often identified along the left cardiac border, aortic arch, descending aorta, and hilar vessels. Subtle findings of ectopic air can confirm the clinical diagnosis of AGE; however, radiographic evidence of concomitant near drowning occurs more frequently.

Adolescent↗
PubMed2004

Spontaneous pneumomediastinum.

Pneumomediastinum is the presence of air in the mediastinum. Spontaneous pneumomediastinum (SPM) is an infrequent, benign, and self-limiting condition that predominantly affects young males and pregnant females. It is important to distinguish pneumomediastinum symptoms from similar clinical findings that require immediate treatment, such as cardiac tamponade, angina pectoris, dissecting aortic aneurysm, mediastinitis, and pulmonary embolism. This report describes 2 cases of SPM managed at University Hospital Hamburg-Eppendorf during the period 2000 to 2001. Spontaneous pneumomediastinum should be considered whenever there are anamnestic data for retrosternal chest pain that radiates to the neck or back accompanied by dysphagia, dysphonia, dyspnea, and a positive Hamman's sign.

Adult↗
PubMed2004

Sports-related spontaneous pneumomediastinum.

BACKGROUND: Spontaneous pneumomediastinum is a rare medical entity occurring almost exclusively in otherwise healthy young individuals without known predisposing factors. We reported our experience with patients presenting with spontaneous pneumomediastinum related to sports. METHODS: Between January 1991 and December 2002, 10 patients were admitted with spontaneous pneumomediastinum related to sporting activities. We retrospectively reviewed their medical records with regard to predisposing factors, clinical presentation, diagnostic evaluation, and outcome. RESULTS: The mean age of our patients was 18.9 years (range 15 to 25 years). Retrosternal chest pain was the most common symptom (90%), and subcutaneous emphysema the most common physical finding (90%). Hamman's sign was present in 9 patients. In all 10 patients, physical exertion during sports was the only implicating factor (scuba diving in 4 patients, basketball in 2, soccer in 3, and volleyball in 1). All patients were treated conservatively. Complete resorption of the pneumomediastinum occurred in 3 to 8 days. Hospital stay ranged from 2 to 6 days (mean 3.8 days). Follow-up was complete in 8 patients (80%), and ranged from 6 to 84 months (mean 35 months). Only 1 recurrence of pneumomediastinum was found that was treated similarly. CONCLUSIONS: Spontaneous pneumomediastinum after sporting activities is a benign disease that generally resolves without clinical sequelae. Restriction of physical and athletic activity after the first episode is unnecessary, the only exception being that of scuba diving.

Adolescent↗
PubMed2004

Weaning from ventilator after cardiac operation using the Ciaglia percutaneous tracheostomy.

OBJECTIVE: To determine the predictors of weaning from mechanical ventilation after cardiac operation with the Ciaglia percutaneous dilatational tracheostomy (PDT) in our preliminary experience in the use of this technique. METHODS: We prospectively analysed 33 consecutive patients (mean age 70.9+/-12.7 years) who underwent PDT in our intensive care unit after cardiac operation. The investigation involved preoperative and postoperative clinical status, operative procedure, indication and timing for PDT. RESULTS: PDT was performed after a mean time of 7.7+/-5.0 consecutive days of translaryngeal intubation. Twenty-four (73%) patients were weaned from ventilator after a mean time of mechanical ventilation of 15.8+/-9.1 days. Time point of PDT was the only predictor of ventilator weaning (P=0.0029): there was significant association between PDT performed before the seventh consecutive day of translaryngeal intubation (early PDT) and successful weaning from ventilator (P=0.01; odds ratio=11.2, 95% confidence interval=1.2-104.3). Among the patients weaned from ventilator, those who underwent early PDT had significantly shorter times of mechanical ventilation, and intensive care unit and hospital stays than patients with later PDT (P=0.035, 0.011 and 0.0073, respectively). Nine (27%) patients died of their underlying disease while still being mechanically ventilated; another six (18%) spontaneously breathing but still incannulated patients died afterward. No major PDT-related complications were observed. Two minor peristomal bleedings and one self-resolving subcutaneous emphysema were recorded. CONCLUSIONS: Early PDT was a safe and effective method to wean from mechanical ventilation the cardiosurgical patients of this series.

Aged↗
PubMed2006

Successful use of a single chest drain postlobectomy instead of two classical drains: a randomized study.

OBJECTIVE: To compare surgical results and complications in the immediate postoperative course between the use of a single drain and two-drain post-anatomical pulmonary resections. PATIENTS AND METHODS: Between January 2004 and September 2005, 143 patients were scheduled for pulmonary lobectomy or bilobectomy for non-small cell lung cancer (NSCLC) in our department. Pneumonectomies, wedge resection, and nonresectable thoracotomies were excluded from the study. Hundred and nineteen patients were enrolled in this study. Clinical and surgical variables were collected prospectively. Lobectomy or bilobectomy and systematic mediastinal node dissection were performed in all cases. The patients were randomly assigned to receive single (group A) or two (group B) drains, independent of any preoperative or intraoperative variables. Group A consisted of 60 patients who had one single drain sited in the mid-position and group B consisted of 59 patients who had two classical drains (apical and basal). There were no surgical, oncological, or physiological differences between the groups (p=NS). RESULTS: There were no statistically significant differences detected between the groups in relation to postsurgical morbidity or mortality and other issues studied, except in analgesia requirements (group A less than group B, p<0.05). After drain removal there were no significant differences between the groups in terms of subcutaneous emphysema, new drains needed, residual pleural effusion, or residual space (p>0.05). CONCLUSIONS: In our study, we did not find significant differences between the use of one or two drains after lobectomy or bilobectomy in relation to early postoperative outcome. However, the use of only one drain is more economical and is less painful for patients, without any additional adverse consequences.

Aged↗
PubMed2006

Closure of tracheocutaneous fistula in children.

OBJECTIVE: Determine the outcome following tracheocutaneous fistula excision with tracheal closure in children, and in particular, evaluate the occurrence of air leak and the implications this has on recommended duration of post-operative hospitalisation. METHODS: Retrospective chart review in a tertiary pediatric hospital. RESULTS: There were 16 patients (6 male:10 female), 15 of whom underwent tracheocutaneous fistula excision with primary wound closure. The mean age at decannulation was 54.2 months and the mean age at repair was 66.2 months. All patients had successful closure of their wound and there were no complications associated with tracheal air leak and subcutaneous emphysema. One patient required the initiation of nocturnal continuous positive airway pressure therapy following repair, and a further two patients had complications related to urinary tract infection and upper respiratory tract infection. CONCLUSIONS: Our experience suggests that management of pediatric tracheocutaneous fistulae by excision and primary closure with a short period of post-operative observation can be undertaken safely.

Child, Preschool↗
PubMed2004

Diagnosis and treatment of traumatic intrathoracic major bronchial disruption.

UNLABELLED: The purpose of this study was to review our experience with intrathoracic major bronchial disruptions due to trauma and to describe the diagnosis and treatment. METHODS: A retrospective review was performed of major bronchial injuries managed in Kuwait (1995-2001), n=12. Clinical presentation, diagnostic evaluation, surgical management, and outcome were reviewed. RESULTS: The mechanism of injury involved blunt trauma in seven patients and penetrating trauma in five. Tachypnea and subcutaneous emphysema (occurring in 10, 9 of the patients, respectively) are common. Nine patients had pneumothorax and air leak after tube thoracostomy. The diagnosis was confirmed by bronchoscopy in all patients. The majority of the injuries were repaired primarily. Lung resection was necessary in two patients. Four patients sustained complications including death (two patients), atelectasis (one patient), and pneumonia (one patient). Follow-up bronchoscopy revealed no evidence of granulation tissue or stenosis at the site of repair. CONCLUSION: The diagnosis of intrathoracic major bronchial disruptions required a high index of suspicion and liberal use of bronchoscopy. The majority were repaired primarily with good outcome.

Adolescent↗
PubMed2005

Percutaneous transesophageal gastrostomy tube for decompression of malignant obstruction: report of the first case and our series in the US.

BACKGROUND: Historically, surgical gastrostomies, gastrojejunostomy, and percutaneous endoscopic gastrostomy have been used palliatively. Recently, enteral stenting has also provided a means of reestablishing gastrointestinal flow in proximal and colonic obstructions. STUDY DESIGN: Seven patients with known intraabdominal malignancy leading to gastrointestinal obstruction were evaluated for PTEG. Ultrasonography, fluoroscopy, and a rupture-free balloon were used in placement. An endoscope was not used. Consent was obtained from all patients. The procedure was performed by a single surgical endoscopist in an endoscopy suite. Patients had appropriate hemodynamic monitoring with pulse oximetry, and they were given preprocedure antibiotics and sedation. RESULTS: PTEG was successfully placed and alleviated symptoms in all seven patients. One complication occurred; in the fourth patient subcutaneous emphysema developed on postoperative day 1, and was managed nonoperatively. All patients were discharged from the hospital. CONCLUSIONS: PTEG is a safe and effective technique for decompression in malignant gastrointestinal obstruction.

Aged↗
PubMed2004

Diagnosis and initial management of laryngotracheal injuries associated with facial fractures.

INTRODUCTION: Laryngotracheal injuries are uncommon with an estimated incidence of 1 per thousand (1-6 patients per 15000-42500 trauma victims). They may be associated with fractures of the facial skeleton. Their symptoms are variable ranging from obvious airway obstruction to minor or almost missing symptoms. Early diagnosis and proper initial management may sometimes be difficult or delayed. PATIENTS: Three patients with maxillofacial fractures and concomitant laryngotracheal injuries are presented. The diagnostic procedures used and the management of these injuries are reported. DISCUSSION AND CONCLUSION: Due to their low incidence and their hidden nature laryngotracheal injuries may pose diagnostic problems, especially in polytraumatized or intubated patients. Subcutaneous emphysema is the chief clinical sign. Fibreoptic endoscopy is the most important and informative diagnostic examination. Radiographic evaluation by CT scan provides additional information about the extent of the injury and the indication for surgery. A coordinated team approach is necessary for proper management of these injuries.

Adult↗
PubMedDate not supplied

Laparoscopic management of endometrial cancer in nonobese and obese women: A consecutive series.

STUDY OBJECTIVE: To assess the technical feasibility and surgical outcome of a 5 mm-ports technique in a consecutive series of women with endometrial cancer laparoscopically managed. DESIGN: Prospective collaborative cohort study (Canadian Task Force classification II-2). SETTING: Two gynecologic oncology units of university hospitals. PATIENTS: A series of consecutive patients undergoing laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy for the treatment of endometrial cancer. INTERVENTIONS: A 10-mm zero-degree umbilical operative laparoscope and three 5-mm suprapubic trocars were used. The lymph nodes were removed with the use of a specimen bag through the umbilical port. Intraoperative and postoperative details and complications were prospectively collected. MEASUREMENTS AND MAIN RESULTS: A total of 101 patients were enrolled. Twenty-two (21.8%) had a body mass index (BMI) of 30 kg/m2 or higher, and nine (8.9%) were severely obese (BMI > or =35 kg/m2). One hundred procedures (99%) were carried out entirely with only three 5-mm ancillary trocars. In one patient, a 5-mm trocar was replaced with a 10-mm trocar because of a lesion of the external iliac vein requiring the placement of vascular clips. One procedure needed to be converted to laparotomy. Intraoperative complications occurred in three patients (one bladder injury and one iliac vein injury, both managed laparoscopically, and one subcutaneous emphysema). Postoperative complications occurred in 10 (10%) patients. The only complication requiring a subsequent intervention was a symptomatic pelvic lymphocyst. No difference was found in surgical outcomes between obese women and those of ideal BMI. CONCLUSION: The use of only 5-mm ancillary trocars for the laparoscopic treatment of endometrial cancer can further minimize surgical invasiveness without compromising surgical efficacy and safety in patients with high BMI as well as for women with ideal BMI.

Adult↗