Pneumomediastinum and Retroperitoneal Air after Removal of Papillomas with the Microdebrider and Jet Ventilation H. Steven Sims, MD and Keith Lertsburapa, MD
Objective: To discuss the complication of pneumothorax from alveolar rupture after transtrocheal high-frequency jet ventilation and to present a case of pneumothorox, pneumomediastinum and pneumoperitoneum after jet ventilation coupled with use of the microdebrider. Method: Detoiled cose report Results: Unilateral pnuemothorax, subcutaneous emphysema, pneumomediastinum and retropentoneal air discovered after jet venfilation for removol of airway papillomas resolved with conservative management. Discussion: We discuss the difference between the respective patterns of air seepage in a peripheral alveolar injury versus a probable microperforation in the trachea. We also review the epidemiology of this rare disorder and its incidence in the African-Amencan community. Conclusion: The recurrent nature of this disorder mandates multiple surgical procedures. Great care must be taken to eradicate disease and avoid complications. Pneumomediastinum in this setting can be managed conservatively. Key words: anesthesia * airway management U papilloma * Afncan Amencans © 2007. From Chicago Institute for Voice Care (Sims, assistant professor/director) and General Surgery/Otolaryngology (Lertsburapa, intern), University of Illinois at Chicago, Chicago, IL. Send correspondence and reprint requests for J NatI Med Assoc. 2007;99:1068-1070 to: Dr. H. Steven Sims, Director, Chicago Institute for Voice Care, 1855 W. Taylor St., Room 2.42, Chicago, IL 60612; phone: (312) 996-6583; fax: (312) 996-4910; e-mail:
[email protected]
INTRODUCTION R5 ecurrent respiratory papillomatosis (RRP) remains a difficult disorder to eradicate. Its association with the human papilloma virus (HPV) types 6 and 11 is understood, but we cannot preempt transmission at this time. Though disease can be confined to the glottis, mucosa lining the entire respiratory tract-from the nasal vestibule to the terminal bronchi-is at risk. Approximately 15,000 procedures are performed annually in the United States for adults and children with RRP. The associated economic impact is approximately $150 1068 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
million each year.4 The correlation of disease incidence with genetics, socioeconomic status and environmental factors remains a subject of great interest.2'5 Laryngologists may require access to the entire airway, and the presence of an endotracheal tube can be more prohibitive than assistive. For larger tracheal lesions, apneic technique may also be a suboptimal approach. Transtracheal jet ventilation resolves this dilemma but also adds potential sources of complications. Airway barotrauma and consequent pneumothorax is a well described complication,"3 but we describe a pattern of air egress that suggests a central rather than peripheral etiology. Mucosal injury is known to occur with airway foreign-body removal with forceps.7 The microdebrider5 may pose less risk of mucosal injury, but small integrity breeches may occur. Coupled with high pressure airflow, these breeches may lead to a pneumothorax, pneumomediastinum, and retroperitoneal air.
CASE REPORT A 22-year-old African-American male presented with an approximately 17-year history of recurrent respiratory papillomatosis. Management over this protracted period of time had included carbon dioxide laser excision, microdebrider excision, adjuvant cidofovir and a trial of adjuvant interferon in the past. The lesions that precipitated his created complaints of increasing dyspnea are clearly seen in the first figure. Anesthesia was induced via mask ventilation, after which direct laryngoscopy allowed us to secure the airway. A 7.0 French catheter was then passed through a channel of the laryngoscope into the tracheal lumen (Figure IA). This approach avoids tracheal puncture. Airway inspection revealed a tracheal lesion distal to the infraglottic confluence (Figure 1B). The microdebrider offered the advantage of being able to reach the distal tracheal papilloma. A Tri-cut® Xomed/Medtronics 27.5cm microdebrider blade was coupled with an Olympus telescope to remove the lesion for optimal control and visualization. The airway was maintained with subglottic jet ventilation until the infraglottis was cleared and the tracheal lesion removed. Pressure was not allowed to VOL. 99, NO. 9, SEPTEMBER 2007
PNEUMOMEDIASTINUM AND RETROPERITONEAL AIR
exceed 40 lbs per square inch (psi). Approximately 45 bursts were delivered per minute. Total time for jet ventilation was 66 minutes. After clearing the lower airway and infraglottis of papillomas, a 6.0 laser-safe, reinforced tube was used to intubate the patient and continue. The carbon dioxide laser was used to remove sessile papillomas along the vocal fold mucosa, in the laryngeal ventricles and on the supraglottic mucosa. Initially, there was evidence of retained carbon dioxide and hypoxia, but oxygen saturation rapidly returned to preoperative values. We also noted slightly increased airway resistance, but this also normalized in a matter of minutes. After emerging from anesthesia, the patient denied any shortness of breath and clinically, felt well. As per routine, a postoperative chest x-ray was ordered. The image revealed a right pneumothorax of approximately 40% and a pneumomediastinum. We obtained a computerized axial tomography (CT) scan of the chest and larynx, which revealed subcutaneous emphysema, a right pneumothorax, pneumomediasFigure 1. A) Preoperative photograph of infraglottic and subgloftic papillomas. Note airway compromise and the presence of jet ventilation catheter.
__~~~~~I
tinum and retroperitoneal air (Figure 2). Comparison of the chest x-ray taken in the immediate postoperative period and the chest CT taken hours later showed interval improvement pneumothorax. After a discussion with thoracic surgery, we opted for conservative management given the absence of airway symptoms or cardiac compromise and improving radiographic findings. The patient was admitted for cardiopulmonary monitoring. After six hours of clinical stability, he was allowed to eat. Continuous pulse oximetry chronicled oxygen saturation of .96% on room air during his stay. Serial x-rays confirmed maturing resolution ofthe pneumothorax. He was discharged home after 24 hours. Follow-up chest x-ray at 72 hours showed miniscule air in the anterior mediastinum and complete resolution of all other findings.
DISCUSSION In the setting of expiratory obstruction, consequent pulmonary hyperinflation may cause subcutaneous emphysema, pneumothorax and pneumomediastinum. In our case, a patent airway was maintained throughout the procedure and expiratory airflow was not compromised. We also considered the possibility of excessive pressure during the delivery of individual oxygen bursts. Pressure was kept below 40 psi, and a review of the literature suggests that control of airway pressure alone may not remove the risk of developing pneumothoraces.3 Careful review of the chest CT failed to reveal a visible defect in the tracheal wall. The pattern of air flow with a large anterior mediastinal collection and ascent into the cervical subcutaneous tissues, however, is consistent with a breech of the continuity of the anterior tracheal wall and consequent airflow superiorly and inferiorly along paths of lesser resistance. These microperforations are too small to be visible during bronchoscopy or on radiographs. They are large enough, however, to permit air egress and its consequences. It is likely that the small mucosal defects sealed in the absence of a pressure head created by jet ventilation. Spontaneous recovery ensued, and antibiotic therapy
0. .,:Eial ~ ~ ~ ~ ~ ~. . .
B) Intratracheal masses seen. Access to lower airway required to remove these lesions. Apneic technique not necessarily suitable.
Figure 2. CT chest and abdomen reveal retroperitoneal air and confirm right pneumothorax, pneumomediastinum and cervical subcutaneous air
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
VOL. 99, NO. 9, SEPTEMBER 2007 1069
PNEUMOMEDIASTINUM AND RETROPERITONEAL AIR
was not required. During the entire postoperative convalescence the patient was clinically asymptomatic. Merati et al. investigated the clinical utility of routine chest roentgenograms. They concluded that this issue requires further investigation, but they support conservatism until a protocol is devised.6 Since no direct intervention was required, one can argue that management would not have changed if the films had not been obtained. Notwithstanding, had we relied on symptoms only, we would not have been aware of this complication, and he would have been discharged as per outpatient surgical routine. He displayed no evidence of cardiac or respiratory compromise, but failure to diagnose and document his condition could certainly have introduced medico-legal inquiry. It may be wise to consider obtaining postoperative films in any patient who underwent jet ventilation and use of the microdebrider to remove tracheal lesions. While subclinical barotrauma is unlikely, the use of the powered instrumentation, such as the Tri-cut blade, introduces a different mechanism by which complications may occur. It may be wise to use the less-aggressive skimmer blade, though these blades may not be long enough to reach distal tracheal lesions. Incorporating this etiology may require alteration of a protocol for the indications of postjet ventilation films. Enigmatic aberrations such as carbon dioxide retention and hypoxia in the setting of intubation after jet ventilation may also be helpful, although these are very nonspecific findings and insufficient to dictate a protocol. Novel laser technology has fostered the emergence of office-based management of papillomas. The role of routine postprocedure chest roentgenograms is yet to be determined. Whether office-based or surgical center management is chosen, the recurrent nature of RRP prompts one to consider the possibility of weakened integrity of the tracheal wall after multiple procedures and the possibility of creating mucosal breeches either with powered instrumentation or a fiber laser. In the absence of a high-pressure ventilation system, these risks may be reduced, and this is a potential advantage of an officebased approach. A complete analysis of the risk-benefit-cost ratio would better clarify the relative merits of each protocol.
REFERENCES 1. Bacher A, Lang T, Weber J, et al. Respiratory Efficacy of Subigottic Low Frequency, Subglottic Combined Frequency, and Supraglottic Combined Frequency Jet Ventilation During Microlaryngeal Surgery. Anesth Anaig. 2000;91:1506-1512. 2. Bonagura VR, Vambutas A, DeVoti JA, et al. HLA Alleles, INF-y Responses to HPV-1 1 E6, and Disease Severity in Patients With Recurrent Respiratory Papillomatosis." Hum Immunol. 2004;65:773-782. 3. Bourgain JL, Desurennes L, Fischler, M, et al. Transtracheal High Frequency Jet Ventilation for Endoscopic Airway Surgery: a Multicentre Study. Br J Anest. 2001 ;87(6):870-875.
1070 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
4. Derkay CS, Darrow DH. Seminar Series: Recurrent Respiratory Papillomatosis. Ann Otol Rhinol Laryngol. 2006;1 15(1):] -1 1. 5. El-Bitar MA, Zalzal GH. Powered Instrumentation in the Treatment of Recurrent Respiratory Papillomatosis. Arch Otolaryngol Head Neck Surg.
2002; 128:425-428. 6. Merati AL, Sale KA, Toohill RJ. The Utility of Routine Chest Radiography Following Jet Ventilation in Elective, Laryngotracheal Surgery. Laryngoscope. 2004;: 14:1399-1402. 7. Zambelli AB. Pneumomediastinum, pneumothorax and pneumoretroperitoneum following endoscopic retrieval of a tracheal foreign body from a cat. J S Afr Vet Assoc. 2006;77(1):45-50. 1
We Welcome Your Comments The Joumal of the Notional Medicol Association welcomes your Letters to the Editor about articles that appear in the JNMA or issues relevant to minority healthcare. Address correspondence to
[email protected].
~
MO4EIjjOUSE SCHOOL OF MEDICINE
The Department of Obstetrics and Gynecology is recruiting for full-time, generalist, faculty physician, open rank, in the Clinical Professor Series. This individual will spend the majority of time commitment in direct patient care. Responsibilities of this position include inpatient and outpatient Ob/Gyn case management, surgery and procedures, and participating in teaching activities with residents and medical students. Some research interest is desirable.
Applicants must meet the following requirements: Successful completion of residency training in obstetrics and gynecology; board eligibility/certification in Ob/Gyn; must possess or be eligible for medical licensure in the State of Georgia; demonstrated clinical skills, judgment and teaching effectiveness; demonstrated ability to establish a good rapport with physician colleagues, residents in training, medical students, nursing staff, patients and support staff. Send curriculum vitae to: Roland Matthews, M.D., Chair, Department of Ob/Gyn, Morehouse School of Medicine, 720 Westview Drive, SW,Atlanta, GA 30310 or by email: obun(W)msm.edu MSM is an equal opportunity, affirmative action employer.
VOL. 99, NO. 9, SEPTEMBER 2007
