A 52-year-old smoker woman presented to our hospital with a 6-week history of anorexia, weight loss, fatigue, productive cough, exertional dyspnea, and hoarseness. She was diagnosed with pulmonary and probable laryngeal tuberculosis and was commenced on a 6-month, antituberculous drug regimen. Clinical course was uneventful and she was discharged 7 days after admission without breathlessness and with minimal dysphonia.
At a 3 month follow-up visit, the patient complained of worsening exertional dyspnea for the previous month, without other associated symptoms. Chest x-ray displayed no signs suggestive of active pulmonary tuberculosis. Dual bronchodilator therapy was prescribed but, as dyspnea turned out to be refractory, spirometry was done. The flow-volume loop was diagnostic of fixed upper airway obstruction (Fig. 1). Bronchoscopy revealed an approximate 90% tracheal stenosis about 3.5 cm below the glottis (Fig. 2, A) which prevented bronchoscope from passing through the stenosis. A subsequent chest CT scan showed severe proximal tracheal narrowing (Fig. 2, B-D). Tracheal aspirate samples were negative for acid-fast bacilli and their culture did not yield Mycobacterium tuberculosis. Rigid bronchoscopy with balloon dilatation (Storz, California, US) under general anesthesia was scheduled. The first session was initially performed with a bronchoscope of 7.5 mm outer diameter, then substituted for another of 8.5 mm. Following this session, residual stenosis was almost 30% of the normal tracheal lumen and patient's dyspnea alleviated considerably. One year after the first session, however, a second bronchoscopic dilatation was undertaken because her usual exertional dyspnea had recently worsened. This second intervention was done using a bronchoscope of 12 mm external diameter, residual stenosis being around 20% of the normal tracheal lumen. Eventually, she became symptomless. There were no adjunctive treatments given. When last seen, 1 year after the second bronchoscopic session, she remained asymptomatic.