Spontaneous Tracheal Perforation as a Late Complication of Thoracic Irradiation

SESSION TITLE: Disorders of the Mediastinum 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Tracheal injuries are rare, serious conditions that could result in life-threatening complications including pneumothorax, pneumomediastinum, and mediastinitis. Non-traumatic tracheal injuries are rarely encountered. We report a case of spontaneous tracheal perforation associated with thoracic irradiation. CASE PRESENTATION: A 46 y/o male with history of esophageal cancer status post chemoradiation and esophagectomy eight years ago, admitted with respiratory failure requiring invasive mechanical ventilation. Chest xray showed chronic right upper lobe collapse, radiation fibrosis, and airspace opacities suggestive of multifocal pneumonia. He received appropriate antibiotics, and surgical tracheostomy after weaning failure. On fourth week of admission, he developed dyspnea and hypoxia. Computed tomography showed large right apical air cavity communicating with trachea & right main bronchus, & extensive radiation fibrosis. Flexible bronchoscopy confirmed a large posterior tracheal membrane perforation distal to tracheostomy tube, perforations in right mainstem bronchus, and main carina. Thoracic surgery was consulted, unfortunately patient expired after cardiopulmonary arrest during surgery. DISCUSSION: Etiology of tracheal injuries include blunt force trauma, penetrating wounds, and iatrogenic (endotracheal intubation, tracheostomy & bronchoscopy). Spontaneous tracheal perforations are exceedingly rare, there are few case reports of spontaneous tracheal injuries secondary to tracheobronchial infections1,2. Our patient’s tracheal injury is unlikely due to tracheostomy procedure given additional findings of perforations on right mainstem bronchus and carina. We therefore conclude that his tracheal injuries were largely related to severe tracheobronchial tissue weakening due to radiation induced fibrosis and necrosis. Although there are no comparison trials between surgical repair and conservative approach, surgical evaluation is recommended in all cases of tracheal injuries. Nonoperative management have been reported successful in some cases of traumatic tracheal injuries3. Endoscopy is recommended to exclude esophageal perforation. CONCLUSIONS: Spontaneous tracheal injuries are rare, diagnosis is confirmed with bronchoscopy, and surgical evaluation is recommended. Reference #1: Repair of Tracheal Aspergillosis Perforation Causing Tension Pneumothorax. Gonzalez et al Reference #2: Spontaneous Tracheal Rupture Associated with Acquired Tracheobronchomalacia. Tsunezuka et al Reference #3: Conservative Treatment of Tracheal Injuries. Beiderlinden et al DISCLOSURE: The following authors have nothing to disclose: Afoma King, Ilya Berim No Product/Research Disclosure Information