A 20-year-old woman was admitted to her local hospital in June, 2010 because of cough and expectoration for 3 months. She was diagnosed as tracheal tuberculosis according to the positive acid-fast bacilli in her sputum and granuloma-like lesions on the tracheal wall with caseous necrosis by bronchoscopy with biopsy. She was given anti-TB medications consisting of Isoniazid (INH), Rifampicin (RFP), Ethambutol (EMB) and Pyrazinamide (PZA). However, her symptoms were not relieved, but deteriorated after 1 month. The bronchoscopy was performed again, revealing tracheal scar stenosis. The biopsy showed chronic inflammation of the upper tracheal mucosa with fibrous tissue proliferation. She was admitted to our hospital on December 9, 2010 for further treatment.
On admission, physical examinations showed that she was clear-minded, breath was 25 times per min, pulse was 93 beats per min, and blood pressure was 126/78 mmHg. On chest examination, her breath sound was rough with wheeze on both sides. The result of abdominal examination was normal. Pulmonary function testing (PFT) showed that her pulmonary function was impaired [vital capacity (VC) =3.29 L (91.9 % pred), the forced expired volume in 1 s (FEV1) =1.11 L (35.2 % pred), the ratio between FEV1 and the forced vital capacity (FEV1/FVC) =33.65 %]. A chest computed tomography (CT; Fig. 1) revealed tracheal stenosis at the thoracic inlet, patchy, nodule-like and streaking lesions with uneven density in both lobes of the lung, and normal lymph node sat mediastinum and lung hilus.
After admission, she continued to receive anti-TB drugs (INH, RFP, EMB and PZA), and then changed to anti-TB drugs [INH, RFP, EMB and streptomycin(SM)] due to liver injury. Electronic bronchoscopy was performed at 3 days after admission (December, 13) under general anesthesia. Mechanical ventilation was used to assist her breathing. The bronchoscopy showed a ring-like scar stenosis about 2 cm below the normal glottis. The bronchoscope (BF BC-260, Olympus Corporation, Tokyo, Japan) with an external diameter of4.9 mmcould pass through the stenosis, but not the bronchoscope (BF IT-260, Olympus Corporation, Tokyo, Japan) with the outer diameter of 5.9 mm. The bronchoscopy (BF BC-260) revealed that the airway wall was rough, the narrowed airway was about 5 cm in length, and the lower end of the stenosis was about 5 cm away from the sharp tracheal carina. No abnormality in the bilateral lobar bronchus was observed.
The tracheal stenosis was treated using the MK58880balloon (1 cm in diameter, Boston Scientific Cork Company, Ireland) with the pressure increased to 303.9 Kpa (3 atm) to dilate the trachea for 10s during which the mechanical ventilation was stopped. Subsequently, the pressure started to decrease and the mechanical ventilation was recovered. The balloon dilatation was repeated 3 times. The bronchial lumen expanded only slightly following the procedure (Fig. 2a, b). On the second day of the balloon dilatation, her symptoms including coughing, shortness of breath, were alleviated. The wheeze and stridor of lungs were reduced under physical examination.
Ten days later, she received bronchoscopic re-examination of the airways and the results still indicated that the bronchoscope (BF BC-260, Olympus Corporation, Tokyo, Japan) could pass through the stenosis, but not the bronchoscope (BF IT-260, Olympus Corporation, Tokyo, Japan). Thus, the high-pressure balloon dilatation treatment was performed again during which the pressure of the balloon was increased to 5 atm and then maintained for 10 s. After 8 inflation cycles, the bronchoscope (BF IT-260, Olympus Corporation, Tokyo, Japan) can pass through the stenosis. However, her cough and shortness of breath symptoms were deteriorated following the treatment, which may be caused by the presence of bronchial edema and spasm. These symptoms were resolved by intravenous and intranasal administration of dexamethasone using atomization device. On the third day after treatment, her cough and shortness of breath symptoms were apparently ameliorated. The physical examinations showed that wheeze and stridor of lungs were remarkably reduced. Then, she was discharged.
Fifty days after the treatment, a repeat PFT showed that her pulmonary function was remarkably improved (VC = 3.40 L (94.8 % pred), FEV1 = 2.06 L (65.5 % pred), FEV1/FVC = 60.51 %). A repeat bronchoscopy showed that the ring-like scar stenosis was dilated, allowing the passage of bronchoscopy (BF IT-260, Olympus Corporation, Tokyo, Japan) (Fig. 2c). During her 1 year outpatient follow-up, no tracheal stenosis was observed. Timeline of past history of the patient was listed in Table 1.