Endobronchial laryngeal tumor “embolus”creating respiratory difficulty during surgery: A case report

Introduction

Unusual laryngeal and tracheobronchial obstructing lesions are seen on occasion [1-3]. A patient was evaluated by his primary physician and pulmonologist due to symptoms referable to his chest including a cough and shortness of breath. Evaluation, including lexible bronchoscopy, revealed a primary carcinoma of the left upper lobe of the long.

History

This middle-aged Caucasian male had a greater than 30 pack year history of smoking and complained of a cough with some hemoptysis. Following evaluation, he was referred to us for a possible left thoracotomy and left upper lobectomy or pneumonectomy. On examination there was a slight wheeze with decreased breath sounds in the left upper chest. No laryngeal lesions had been reported.

Surgery

Following endotracheal double lumen tube general anesthesia intubation, the patient was positioned on his right side for a left thoracotomy and possible lobectomy or pneumonectomy. Upon occlusion of the left main stem bronchus to initiate single lung anesthesia, the right lung could not be ventilated. After several attempts to ventilate the patient, the patient was repositioned in the supine position and still could not be ventilated when the left main stem bronchus was occluded until the left mainstream occlusion was released.

Surgical procedure

Transendotracheal tube tracheobronchoscopy revealed a round firm obstructing lesion in the right mainstem bronchus. After multiple attempts to remove the mass utilizing the biopsy forceps, basket snares, and Fogarty balloon catheters, we were able to move the lesion into the trachea but not grasp it. We then placed the patient in an extreme headdown feet up position and removed the endotracheal tube. The endobronchial lesion followed and fell onto the floor with a bounce.

Pathology

The 1.2cm lesion was round, firm, and robbery in consistency and when dropped would bounce. Microscopically it was felt to be a benign adenoma. Repeat laryngoscopy examination revealed the origin of the lesion which was resected., The patient then had resection of the pulmonary carcinoma without additional anesthesia ventilation concerns.

Summary

A middle-aged male individual had a benign adenomatous laryngeal adenoma which “embolized “ distally during induction of general anesthesia for resection of the pulmonary carcinoma. During induction of single lung anesthesia for pulmonary resection, it was not possible to ventilate the patient until the “embolic” and obstructing adenomatous lesion had been removed from the right mainstem bronchus.

1. Dieter RA, Parker P, Cornell R, Hasbrouck P, Lavin FI (1974) Unusual expectoration. Am Fam Physician 10: 112-116. Link: https://bit.ly/2WpS027
2. Dieter RA, Kuzycz GK, Huml J (2001) Resection of a tracheobronchial tumor cast. Chest.
3. Dieter RA (2017) Tracheal resection and pregnancy. Ann Thor Surg 104: 376. Link: https://bit.ly/2Vn3SBp