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Ann Thorac Surg 1998;65:557
© 1998 The Society of Thoracic Surgeons

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Case Reports

Percutaneous Placement of Tracheal T Tube

Section of General Thoracic Surgery, University of Washington, Seattle, Washington, USA

Accepted for publication September 26, 1997.

Dr Wood, University of Washington, Box 356310, 1959 NE Pacific, Rm AA-115, Seattle, WA 98195-6310.

	Abstract

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Tracheal T tubes provide effective palliation of unresectable benign and malignant tracheal obstruction, but placement may be difficult when previous operation, radiation, or tumor limits surgical exposure of the cervical trachea. Percutaneous placement using commercially available percutaneous tracheostomy kits may provide an alternative approach in these cases.

	Introduction

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Initially introduced in 1965 by Montgomery [1] the silicone tracheal T tube has become an established means of providing definitive palliation of tracheal stenosis or obstructing tumor when surgical reconstruction is not possible. Insertion requires surgical exposure of the cervical trachea, which may be very difficult if the neck is scarred from previous surgical procedures, radiation therapy, and recurrent tumor growth. We present a case demonstrating a percutaneous technique for providing palliative airway control in an irradiated, heavily scarred neck with advanced recurrent thyroid cancer.

A 54-year-old woman with known locally recurrent and metastatic papillary carcinoma of the thyroid was admitted with severe dyspnea and stridor. Two years before this admission a papillary carcinoma of the thyroid was treated with total thyroidectomy and neck dissection. Two local recurrences were resected and treated with therapeutic doses of iodine 131, and a third recurrence was treated with external-beam radiation to 60 Gy. One month before admission, the patient presented with a fourth local recurrence with physical examination revealing a red, indurated anterior neck mass with ulcerating tumor nodules. Neck and chest computed tomography revealed multiple lung metastases and a distal intratracheal mass. Systemic therapy was planned but before this could be initiated the patient presented with severe dyspnea and stridor.

Emergent rigid bronchoscopy showed a normal larynx, subglottic larynx, and proximal trachea except for several small mucosal nodules in the trachea. Three centimeters above the carina there was a pedunculated mass, which obstructed approximately 90% of the distal airway. This was easily "cored out" at bronchoscopy and removed as a solid specimen. The neodymium:yttrium-aluminum garnet laser was used to vaporize the tumor base. This resulted in complete relief of airway symptoms. Pathologic examination confirmed histology identical to her thyroid primary tumor.

Systemic chemotherapy with carboplatin and etoposide was initiated and ultimately changed to doxorubicin with a partial clinical response in her large indurated neck mass. However, she required repeat bronchoscopy with mechanical debridement of tumor every 6 to 12 weeks, with bronchoscopy revealing an overall increase in endobronchial tumor involving the mid and distal trachea. Further recurrences were managed by placement of a silicone intratracheal stent (Hood Laboratories, Pembroke, MA). Three months later, proximal and distal progression of tumor beyond the stent required a more durable solution for proximal palliation. Furthermore, the patient had evidence of further tumor growth within the neck with indurated and ulcerated anterior neck lesions. This produced laryngeal edema, and repeat bronchoscopies were becoming increasingly difficult.

A tracheal T tube was selected to provide the most durable and safest palliation of the patient’s recurrent airway obstruction, avoiding the need for repeated bronchoscopy. The anterior neck had a large tumor recurrence with the sequelae of multiple operations and definitive dose radiation significantly compromising any attempts at direct tracheal exposure. A percutaneous tracheostomy kit (Cook, Inc, Bloomington, IN) was used simultaneously with rigid bronchoscopy under general anesthesia, directing the finder needle and guidewire into the trachea at the level of the second tracheal ring. The tract was serially dilated to 36-F. The 28-F dilator was placed within a standard 14-mm tracheal T tube (Hood Laboratories) and these were introduced together through the newly created stoma. After introduction of the dilator and distal limb into the trachea, the dilator was removed, and the T tube was pushed deeper into the trachea until the proximal limb was also intraluminal. Gentle traction on the side limb straightened the T tube and positioned the proximal limb into the upper trachea. Proper seating was assured by bronchoscopy. The patient subsequently had no further airway complaints and required no additional bronchoscopies. Unfortunately, her tumor progressed rapidly in spite of systemic therapy and she died 5 months after placement of her T tube.

	Comment

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Papillary cancer of the thyroid does not commonly compromise the airway, but can cause tracheal obstruction by one of two mechanisms. The most common cause of airway narrowing is from bulky local tumor growth with extrinsic tracheal compression. In general this is managed by repeated local excisions as long as technically feasible. The slow growth and relatively benign natural history of papillary thyroid cancers may allow prolonged patient survival for years or even decades in patients with locally recurrent and metastatic tumors [2]. Less commonly, thyroid cancer may invade the trachea with intrinsic endobronchial obstruction. Although en-bloc resection of the tumor and involved trachea is the ideal treatment for invasive thyroid cancer [2], at times this is not feasible because of the extensive spread of the tumor. Therapeutic doses of iodine 131, external-beam irradiation, systemic chemotherapy, and aggressive surgical palliation by cervicomediastinal exenteration and mediastinal tracheostomy can be used as alternatives for local control of disease producing airway symptoms [2]. All of these had been attempted unsuccessfully in this patient except cervicomediastinal exenteration, which was not indicated due to the aggressiveness of the tumor and the extent of the tracheal involvement.

Tracheal T tubes were introduced by Montgomery in 1965 and can provide effective palliation of tracheal stenosis [1]. If surgical resection and primary reconstruction is not possible, T tubes have also been successfully used to palliate obstruction of the airway as a result of malignant invasion or compression of the trachea [3] [4]. T tubes have several advantages over tracheostomy in that they provide humidification of air through maintenance of nasopharyngeal respiration, are nonirritating to surrounding tissue, and preserve the ability to speak [3].

The T tube has previously been placed through a surgically created tracheal stoma and positioned with the aid of rigid bronchoscopy. However, the creation of a tracheal stoma can be difficult when the surgical planes of the neck have been destroyed by tumor invasion, scarring, and previous irradiation. In these instances percutaneous access to the trachea and subsequent dilation of the tract to create a stoma may provide easier access for placing a T tube.

The technique of percutaneous tracheostomy was first reported by Ciaglia and associates in 1985 [5]. The procedure involves accessing the trachea by inserting a needle into the subcricoid trachea and placing a guidewire through the needle into the trachea using the Seldinger technique. Progressively larger dilators are then placed over the guidewire until a sufficient tract has been made. At this time the tracheostomy tube is then inserted and the wire removed [5]. Several studies have shown that this technique can be performed quickly and safely [6].

The combination of techniques for placement of tracheal T tubes and percutaneous tracheostomy may provide easier control and palliation of the airway than open surgical procedures in certain clinical settings. In this case, an appropriate intratracheal position was quickly established by simultaneous bronchoscopy with needle localization from the anterior neck. The tract was easily dilated through tumor and scar, and a 14-mm tracheal T tube was easily positioned over the 28F dilator.

Percutaneous placement of a tracheal T tube may not readily apply in cases without scarring, induration, or tumor obliterating the normal planes. In these cases it could be that the normal flexibility of the tracheal would prevent successful placement of a T tube without direct exposure and control of the trachea itself. However, in this setting, surgical exposure is easy and is probably the preferable approach. In situations where surgical exposure of the trachea is expected to be difficult, the percutaneous technique described provides an alternative access for placement of a tracheal T tube.

	References

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1. Montgomery WW T-tube tracheal stent. Arch Otolaryngol 1965;82:320-321.
2. Zannini P, Melloni G Surgical management of thyroid cancer invading the trachea. Chest Surg Clin N Am 1996;6:777-790.[Medline]
3. Cooper JD, Thomas RJ, Ilves R, Pearson FG Use of the silicone tracheal T-tube for the management of complex tracheal injuries. J Thorac Cardiovasc Surg 1981;82:559-568.[Abstract]
4. Gaissert HA, Grillo HC, Mathisen DJ, Wain JC Temporary and permanent restoration of airway continuity with the tracheal T-tube. J Thorac Cardiovasc Surg 1994;107:600-605.[Abstract/Free Full Text]
5. Ciaglia P, Firsching R, Syniec C Elective percutaneous dilational tracheostomy. Chest 1985;87:715-719.[Abstract/Free Full Text]
6. Griggs WM, Myburgh JA, Worthley LIG A prospective comparison of a percutaneous tracheostomy technique with standard surgical tracheostomy. Intensive Care Med 1991;17:261-263.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Douglas E. Wood Eric Vallières Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wood, D. E. Articles by Vallières, E. Search for Related Content PubMed PubMed Citation Articles by Wood, D. E. Articles by Vallières, E.