Ann Thorac Surg 1999;68:1182-1186
© 1999 The Society of Thoracic Surgeons
Original Articles
Surgical management of airway obstruction in primary tuberculosis in children
Konstantinos A. Papagiannopoulos, MMEDa,
Anthony G. Linegar, FCS (SA)a,
David G. Harris, FCS (SA)a,
Gawie J. Rossouw, FCS (SA)a
a Department of Cardiothoracic Surgery, University of Stellenbosch, Tygerberg Hospital, Cape Town, South Africa
Address reprint requests to Dr Papagiannopoulos, 27 Ag. Anargyron Str, Marousi, 151 24, Athens, Greece
e-mail: kpapagiannopoulos{at}yahoo.com
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Abstract
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Background. The role of surgery in the management of airway obstruction from lymphobronchial tuberculosis is discussed in the present article.
Methods. Nine patients were operated on over a 4-year period and are currently presented. The age of the patients ranged between 5 and 28 months and 7 patients were male. Six patients required preoperative ventilation due to respiratory failure and all received standard posterolateral thoracotomies. Partial dissection and enucleation of bulky lymph nodes was performed in all but 1 patient. In that patient, the group of lymph nodes could be removed fully, including the sheath.
Results. All patients showed marked improvement and were weaned off the ventilator between 24 and 72 hours postoperatively. Long term follow-up was available in 7 patients and they are all doing well and are free of symptoms.
Conclusions. Enucleation of mediastinal lymph nodes obstructing the airways in young patients with lymphobronchial tuberculosis is safe. It successfully relieves obstruction and is devoid of complication providing that incision, evacuation, and curettage of lymph nodes is performed avoiding overzealous dissection.
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Introduction
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Pulmonary tuberculosis is a disease not often encountered in developed countries, but is still the cause of significant morbidity and mortality in developing countries. Standard treatment remains intensive antibiotic therapy. Despite the general success of conservative treatment, some patients require the intervention of the cardiothoracic surgeon, mainly due to disease complications.
In children, gross enlargement of hilar lymph nodes can be the dominant feature of the primary presentation [1], (Fig 1). Failure of medical treatment in some patients allows the persistently bulky nodes to cause obstruction of the trachea and/or bronchi with segmental or lobar collapse and respiratory distress [2]. Urgent surgical intervention is mandatory to relieve symptoms and protect the lung parenchyma from repeated respiratory infections and their sequelae [3–6]. Interestingly, obstructive emphysema from partial obstruction is relatively rare.
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Fig 1. Deviation of trachea (patient 3) from midline from volume loss of right lung and evident bulky mediastinal lymph nodes.
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The mechanism of obstruction is external compression or erosion and obstruction of the bronchus from caseous material or granulation tissue. What aids in that pathology, is the small size of bronchi in children and the lack of rigidity causing easily collapse of the lumen.
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Patients and methods
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The data presented have been extrapolated from the medical records of both the Department of Pediatrics and Cardiothoracic Surgery of Tygerberg Hospital over a 4- year period (1994–1997).
Table 1 summarizes the clinical presentation of the patients. It should be noted that 5 of the 9 patients were not operated on during the initial admission. Most were known to have pulmonary tuberculosis and were readmitted due to superimposed infections.
Table 2 summarizes the special investigations, invasive and noninvasive, done to study all patients.
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Fig 2. Hilar lymphadenopathy (patient 6) with severe compression of left main bronchus and hyperinflation of left lung due to possible ball-valve effect.
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Table 3 presents information concerning surgery and intraoperative findings. All patients were operated on by 2 surgeons (KAP and AGL).
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Comment
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Hilar lymphadenopathy is a prominent feature of primary pulmonary tuberculosis (Fig 2). It is most often seen in children with variable but unanimously high incidence (47.7%–54%) [3, 4]. Its presence is not an indication for surgery per se unless it causes certain complications, such as: (a) acute perforation of a major airway and severe respiratory embarrassment; (b) pressure and occlusion of major airway with pulmonary collapse or hyperinflation (Figs 1, 2); (c) permanent bronchial stenosis due to fibrosis; and (d) rarely superior vena caval obstruction; or subcarinal esophageal obstruction. The last 2 complications are found in cases of gross enlargement of the lymph nodes.
Gross enlargement has been defined as a lesion occupying a greater space than that between the upper border of the seventh rib and the lower border of the eighth rib posteriorly on a standard posteroanterior chest film. In one study, gross enlargement was found in 8% of cases, with 4% of cases in patients under 5 years of age and 11% in patients aged 5 years and older, with boys affected twice as frequently as girls. Radiologically, the enlargement reaches its maximum 2 to 6 months after the date of the primary infection. The precise course of the glandular enlargement does not appear to be altered by the antituberculosis drugs even if given in large doses over many months [10].
Steroids have been used by many institutions as a useful aid in the therapy of the nodal enlargement [11]. In experimental studies of guinea pigs, steroids reduced both necrosis and formation of epithelioid cells and exert an inhibitory effect on fibrosis. In humans, steroids combined with effective antituberculosis chemotherapy gave good results in certain cases. Best results are obtained with prednisone [11]. It should be noted that isolated hilar lymphadenopathy is not an indication for steroids. Additionally, steroids might promote rupture of lymph nodes in the bronchus with subsequent obstruction and catastrophic sequelae. This was seen especially in those patients with bulky right paratracheal nodes; thus, the use of steroids is prohibited in those patients [11].
The indications for surgery can be grouped as follows [5]:
- Acute perforation of a major airway with severe respiratory embarrassment. The role of bronchoscopy here is very important because suction of caseous material and mucopus is essential to relieve the obstruction. mThe appearances of such pathology have been well described in detail by Podvinec and Erak, who have also drawn attention to the significance of reflex congestion and swelling of the bronchial mucosa in causing bronchial obstruction [12]. A study by Engel in 1947 showed that the infection of the regional lymph nodes draining the primary lung focus is of less significance than the infection of the right tracheo-bronchial and bifurcation nodes. As a result of the anatomical disposition of these nodes, the right main bronchus is particularly liable to compression and perforation. Vosschulte described a case of acute respiratory distress in a 14-year-old boy, caused by perforation of lymph nodes in the lower trachea. He performed a right thoracotomy and enucleated a mass of lymph nodes in the angle between the trachea and the right main bronchus. He also drew attention in operations, done in the past, performed mostly on a mistaken diagnosis of mediastinal tumors as early as 1911 [6]. mAsphyxia from extrusion of a large amount of caseous material is extremely rare but has been reported [6, 10].
- Perforation of glandular mass in a main airway causing recurrent episodes of obstruction. The nodes should be enucleated and the perforation closed. Direct closure with simple suturing is effective in most cases. In more complicated situations, muscle flaps can be used to reinforce the area of perforation. Two such cases have been described in Worthington’s series with the use of pectoralis muscle flap [4]. Others have proposed a Y-V plasty in large perforation of the right main bronchus in order to bring the bronchus close to the trachea.
- Bronchial obstruction and pulmonary collapse lasting more than 1 month. This is a very controversial issue. Macpherson and Lutwyche at the Brompton hospital studied 721 children with tuberculosis for up to 16 years [1]. The incidence of collapse due to hilar lymphadenopathy was 9.9% in those between 0–4 years of age and dropped dramatically to 1.9% in those aged 12 years and older, suggesting that the bronchi of younger infants are more collapsible and thus prone to obstruction. From a total of 42 collapsed lobes, 24% were on the left side and 76% on the right side, with the highest incidence in the right upper and middle lobes. Only 1 patient has finally received a left lower lobe lobectomy. From the rest, only 3 still have lobar collapse, but they are nevertheless asymptomatic. The follow-up period of those patients is up to 17 years. Brock wrote an extensive article on post-tuberculous bronchostenosis of the middle lobe bronchus. In a collective series of 93 cases with lobar collapse, 60 were in the middle lobe. Brock believes that the long middle lobe bronchus with lymph nodes at its inferior part draining also from the lower lobe make it specifically vulnerable to obstruction [2]. Nonetheless, most of those patients remained asymptomatic until adult life. Stevens suggests that one could wait up to 2 years for medical treatment before attempting surgical intervention. Cameron analyzed 48 patients with segmental collapse to establish whether early surgery for prophylaxis is justified. In the long-term follow-up, 11 patients had normal radiographs and bronchograms, 9 had small areas of fibrosis, 2 had punctuate calcification, and 9 had minor bronchiectatic changes and were asymptomatic. Only 5 children with bronchial strictures and 6 with persistent atelectasis or segmental bronchial block had a possibility in gaining from surgery [3].
- Treatment of long-term fibrous bronchial stenosis. Procedures used are: (a) simple stricture excision and primary anastomosis, (b) combined stricture excision and lung resection for destroyed parenchyma, and (c) stricture resection with partial lung resection and conservation of remaining lung with primary anastomosis.
- Residual fibrosis leading to SVC obstruction and subcarinal esophageal obstruction.
In Nakvi’s series, 4 children were operated on for perforation of airways and the remaining 3 for respiratory airway obstruction, emphysema and persistent enlarged nodes. Only one case was done on an emergency basis [13]. In Worthington’s series, 2 out of 13 patients were operated on an emergency basis and the rest between 2 and 49 days after diagnosis [4]. In our series, 6 of the 9 children needed preoperative ventilation. All were operated on for airway obstruction from the bulky nodes and received enucleation of nodes with no additional procedures. All, with the exception of 1, were already on antituberculosis treatment for weeks and 5 had a superimposed infection that worsened the clinical picture. Seven patients were male and the age ranged between 5 and 28 months.
Concerning the surgical technique, standard thoracotomy was performed. Patience and avoidance of overzealous dissection was necessary. The lymph nodes were inflamed and bulky, and they compressed significant structures, making identification in some cases difficult.
We agree with other investigators that overzealous dissection should be avoided. In all cases, we have succeeded with direct partial resection of the lymph nodes and evacuation of mucopus with careful curettage. We encountered no complications in that way. The 1 patient with phrenic nerve paralysis was not a result of surgery since it was evident on preoperative chest radiographs.
Thomas lost 1 patient from an injured pulmonary artery, and Giraud and Metras had difficulty in preserving the bronchial arteries. Worthington encountered complications in 2 patients. The first had a tear in the left main bronchus and was repaired with direct suture and the other had a laceration in the pulmonary artery [4].
In conclusion, patients presenting with respiratory distress due to airway obstruction from enlarged tuberculous lymph nodes need urgent surgical decompression. Prophylactic surgery in the presence of bulky nodes is not recommended even in the presence of mild symptoms; surgery should be reserved in those cases where all attempts for medical treatment have failed; whether plain enucleation or additional procedures are necessary depends on the preoperative evaluation and the interoperative findings; lung resection should be avoided at all costs, because many patients improve on long-term follow-up; the technique of enucleation is of major importance in avoiding complications; nodes should be enucleated and only partially resected with careful evacuation of their contents; and strict follow-up with bronchoscopies and CT scans is necessary, especially in cases of persistent segmental or lobar collapse, to identify endobronchial lesions or destroyed lung tissue, which would necessitate additional future interventions. [7, 8, 9, 14, 15, 16, 17, 18, 19, 20]
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References
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Accepted for publication March 22, 1999.
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Abstract
Introduction
