Abstract
Acquired tracheal pouch known also as tracheocele is a rare air-filled diverticulum of tracheal pars membranacea. This disease may be due to esophageal or tracheal surgery, orotracheal intubation, or increased intralunimal pressure through a weak area of tracheal wall. When symptomatic and medical therapy is insufficient, this disorder must be treated surgically. Several surgical methods ranging from open neck or thoracic surgery to endoscopic managements have been reported. We report the case history of a 7-year-old boy affected by recurrent pneumonia due to tracheal pouch. The patient underwent successful brushing of tracheocele plus fibrin glue application by rigid tracheobroncoscopy. Furthermore, particular emphasis on endoscopic treatments of tracheal diverticulum is also presented.
1
Introduction
Congenital or acquired tracheal pouch is an air-filled mucosal diverticulum of the posterior membranous trachea. The structure is completely covered with respiratory epithelium and has no smooth muscle and/or cartilage in relation to its etiopathogenesis . Acquired tracheal diverticulum may be due to esophageal or tracheal surgery, orotracheal intubation, or increased intraluminal pressure through a weak area of tracheal wall .
When the disease is symptomatic, the clinical picture ranges from recurrent bronchopneumonia to pneumomediastinum. Medical management is first-line treatment, but surgery may become mandatory. To date, several surgical methods ranging from resection of the lesion via transcervicotomic and/or transthoracic approaches to endoscopic electrocauterization of its epithelial lining have been reported . Herein, we report the history of a child affected by acquired tracheal pouch who was successfully treated using endoscopic brushing of the lesion with application of fibrin glue.
2
Case report
In October 2007, a 7-year-old child was admitted for tracheal diverticulum to the Department of Pediatric Otorhinolaryngology, Spedali Civili, Brescia, Italy. At birth, the patient had undergone esophageal atresia and tracheoesophageal fistula correction, and several esophageal dilatations due to stenosis of the esophageal lumen had been performed. During the last 3 years, the child had recurrent pneumonia. In June 2006, a rigid tracheobronchoscopy (RTBS) was performed, which revealed a blind-ending pouch of the tracheal pars membranacea located 1 cm above the carina and associated with purulent secretions flowing into the right main bronchus. For this reason, the patient underwent rigid bronchoscopic curettage of the tracheal diverticulum.
After a few months of overall good health, the patient presented with recurrent pneumonia, and a persistent tracheal pouch was identified at RTBS ( Fig. 1 ). Thus, brushing of the tracheal diverticulum ( Fig. 2 ) associated with application of fibrin glue into the pouch by means of a 4F catheter ( Fig. 3 ) was performed using an endoscopic approach. Excessive glue was removed by suction, and it solidified in a few minutes. The patient remained intubated for 24 hours. No intra- and/or postoperative complications were observed. Then, the patient was given nothing per os for 48 hours. The child was discharged 4 days after intervention and given antibiotic therapy (amoxicillin + clavulanic acid 25 mg/kg BID for 10 days) associated with light diet for 1 week. In December 2007, a tracheal endoscopic examination showed complete obliteration of pouch ( Fig. 4 ) and, at the time of writing, the child is asymptomatic.
2
Case report
In October 2007, a 7-year-old child was admitted for tracheal diverticulum to the Department of Pediatric Otorhinolaryngology, Spedali Civili, Brescia, Italy. At birth, the patient had undergone esophageal atresia and tracheoesophageal fistula correction, and several esophageal dilatations due to stenosis of the esophageal lumen had been performed. During the last 3 years, the child had recurrent pneumonia. In June 2006, a rigid tracheobronchoscopy (RTBS) was performed, which revealed a blind-ending pouch of the tracheal pars membranacea located 1 cm above the carina and associated with purulent secretions flowing into the right main bronchus. For this reason, the patient underwent rigid bronchoscopic curettage of the tracheal diverticulum.
After a few months of overall good health, the patient presented with recurrent pneumonia, and a persistent tracheal pouch was identified at RTBS ( Fig. 1 ). Thus, brushing of the tracheal diverticulum ( Fig. 2 ) associated with application of fibrin glue into the pouch by means of a 4F catheter ( Fig. 3 ) was performed using an endoscopic approach. Excessive glue was removed by suction, and it solidified in a few minutes. The patient remained intubated for 24 hours. No intra- and/or postoperative complications were observed. Then, the patient was given nothing per os for 48 hours. The child was discharged 4 days after intervention and given antibiotic therapy (amoxicillin + clavulanic acid 25 mg/kg BID for 10 days) associated with light diet for 1 week. In December 2007, a tracheal endoscopic examination showed complete obliteration of pouch ( Fig. 4 ) and, at the time of writing, the child is asymptomatic.
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