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| LETTER TO THE EDITOR |
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| Year : 2011 | Volume
: 1
| Issue : 2 | Page : 77-78 |
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Laser excision of tracheal adenoma
A Ravi Kumar, Sandeep Kumar Jha, L Somu, Prasanna Kumar
Department of Otorhinolaryngology and Head and Neck surgery, Sri Ramachandra Medical College and Research Institute, Chennai, India
| Date of Web Publication | 19-Sep-2011 |
Correspondence Address:
Sandeep Kumar Jha
B2, Abhinav Kailash Apartments, 19A, Old Velacherry Road, Little Mount, Saidapet, Chennai - 600 015
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2230-9748.85070
How to cite this article:
Kumar A R, Jha SK, Somu L, Kumar P. Laser excision of tracheal adenoma. J Laryngol Voice 2011;1:77-8 |
Dear Sir,
Primary adenoma of trachea is a rare tumor. Only 34 cases have been reported till date from 1922. [1] Here we present a case of tracheal adenoma that presented to our clinic with hemoptysis and was successfully treated with endotracheal LASER excision. The advantage of this technique was the minimal morbidity, short hospital stay, and rapid recovery of the patient.
A 58-year-old man presented to the Otorhinolaryngology and Head and Neck Surgery of our hospital with complaint of recurrent cough for 7 months associated with recurrent bouts of hemoptysis. Over the past 1 month he also had increasing difficulty in breathing on exertion. The patient gave no history of fever, loss of weight, or appetite. There was no history suggestive of substance abuse or any comorbid illnesses, such as diabetes mellitus and hypertension.
A thorough physical examination showed a well-oriented healthy adult man with no apparent respiratory compromise. ENT, chest, cardiovascular, and abdominal examination were within normal limits. A detailed evaluation was carried out by pulmonologists. Spirometry showed a mild obstructive pattern. Subsequently, the patient was subjected to videolaryngoscopy, which also showed a normal larynx.
Thereafter computed tomographic scan of chest and neck was performed, which showed pedunculated growth of size 1.3 Χ 1.4 cm arising from the left posterolateral wall of the tracheal lumen, 2 cm below the vocal cords occluding 70% of tracheal lumen [Figure 1]. | Figure 1: Computed tomographic scan showing pedunculated growth of size 1.3 × 1.4 cm arising from the left posterolateral wall of the tracheal lumen, 2 cm below the vocal cords occluding 70% of tracheal lumen
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Subsequently, flexible fiberoptic bronchoscopy and punch biopsy was performed.
Histopathology showed tubular gland arranged back to back lined by a single layer of columnar epithelial cells with round vesicular nucleus and moderate amount of cytoplasm, suggestive of a benign tracheal adenoma.
Considering the high location of the tumor, an elective low tracheotomy at the level of 5 th and 6 th tracheal rings under monitored anesthetic control was performed. It was followed by endobronchial LASER excision of the mass in toto with KTP-532 LASER at 4 W through a 0.4 mm fiber in near-contact mode under general anesthesia. Histopathological examination of the tumor mass showed features suggestive of tracheal adenoma [Figure 2]. | Figure 2: Histopathologic examination showed tubular gland arranged back to back lined by a single layer of columnar epithelial cells with round vesicular nucleus and moderate amount of cytoplasm, suggestive of a benign tracheal adenoma
Click here to view |
The patient was decanulated on the 2 nd postop day and was discharged subsequently in a stable condition. Bronchoscopy 6 months postoperatively showed a normal trachea with no evidence of recurrence.
Tracheal tumors are a rare occurrence. Many of these patients in the past were left undiagnosed. This was because of their varied clinical presentation ranging from asymptomatic [2] to features suggestive of asthma [3],[4] and in some cases with hemoptysis, thus misleading the treating doctor to treat conditions, such as tuberculosis or malignancies, as in this case. With the advent of fiber optic bronchoscopy, diagnosis of this pathologic condition has become easier though caution is needed in case of a negative bronchoscopy. [5] Even though the bronchoscopy provides a direct visualization of the tracheal lumen, small submucosal lesions may be missed.
The treatment of benign tracheal adenomas has conventionally been sleeve resection and end-to-end anastomosis of the trachea. [6],[7] But with the advent of endoscopes, bronchoscopes, and laryngoscopes and with better anesthetic management and instrumentation, it is possible now to remove these tumors transluminally as done in this case. Use of endoluminal LASER as in this case and reported in literature helps in near atraumatic and bloodless field of surgery. [8]
The standard protocol for management for such tumors should include a thorough evaluation of the patient to rule out any other similar hamartomatous lesions. A careful evaluation of the tumor with a bronchoscope and a biopsy should be done to rule out the presence of malignancies, [9] such as adenoid cystic carcinoma, squamous cell carcinoma, and mucoepidermoid carcinoma. Such malignancies need to be treated on their own merit. Once the benign nature of the tumor is established, it is prudent to establish the exact location of the tumor. That may help in defining the need or usefulness of an elective tracheotomy as in this case. The high location of tumor in this case made it difficult for the anesthetist to manipulate the airway as it could lead to dislodgement of the tumor. Further the propensity of the tumor to bleed could put the patient in jeopardy. To avoid this we performed a low tracheotomy to secure the airway and to keep the anesthetic agents out of the surgical field as the tumor was located way above in the trachea at the level of 2 nd and 3 rd tracheal rings. Once the airway is secured, the tumor can be visualized using standard laryngoscopy techniques. Thereafter, the tumor was removed with the use of KTP-532 LASER. The advantage of using the LASER was a near bloodless field and precision of cutting through the tumor base. The effectiveness of this technique can be established from the fact that the patient was asymptomatic at 6 months follow-up with normal tracheal lumen.
Based on our experience, we advice such cases of benign tracheal lumen tumors to be treated with endoluminal LASER excision as it allows for a curative therapy to be performed in a blood less operative field without the complications associated with the open sleeve resection and anastomoses techniques. Furthermore, the hospital stay and recovery time are reduced and the patient is able to return to normal function early on. The conventional technique of sleeve resection and anastomoses may be reserved for recurrences following the primary endoluminal approaches.
 References | |  |
| 1. | Rodriguez MJ, Thomas GR, Farooq U. Pleomorphic adenoma of the trachea. Ear Nose Throat J 2008;87:288-90. 
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| 2. | Gautam HP. Asymptomatic mediastinal mass situated posterolateral to the trachea. Br J Clin Pract 1970;24:390-1.
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| 3. | Ferguson CJ, Cleeland JA. Mucous gland adenoma of the trachea: Case report and literature review. J Thorac Cardiovasc Surg 1988;95:347-50.
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| 5. | Lee CJ, Lee CH, Lan RS, Tsai YH, Chiang YC, Wang WJ, et al. The role of fiberoptic bronchoscopy in patients with hemoptysis and a normal chest roentgenogram. Changgeng Yi Xue Za Zhi 1989;12:136-40.
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| 6. | Takeda S, Hashimoto T, Kusu T, Kawamura T, Nojiri T, Funakoshi Y, et al. Management and surgical resection for tracheobronchial tumors institutional experience with 12 patients. Interact Cardiovasc Thorac Surg 2007;6:484-9.
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| 7. | Kim KH, Sung MW, Kim JW, Koo JW. Pleomorphic adenoma of the trachea. Otolaryngol Head Neck Surg 2000;123:147-8.
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| 8. | Newhouse MT, Martin L, Kay JM, Miller JD. Laser resection of a pedunculated tracheal adenoma. Chest 2000;118:262-6.
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| 9. | Schneider P, Schirren J, Muley T, Vogt-Moykopf I. Primary tracheal tumors: Experience with 14 resected patients. Eur J Cardiothorac Surg 2001;20:12-8.
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[Figure 1], [Figure 2]
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