When Asthma Isn't Asthma: A Tracheal Schwannoma Masquerading As Small Airway Obstruction
Kyle W. Riggs1, Amie Kent1, Clancy Mullan2, Sanjeev Ponnappan1, Paul C. Lee1, David Zeltsman1.
1Northwell Health, Manhasset, NY, USA, 2Hofstra Northwell School of Medicine, Hempstead, NY, USA.
OBJECTIVE: Primary tracheal tumors are rare entities and tracheal Schwannomas even more uncommon. These can grow slowly and have minimal symptoms until nearly the entire airway is obstructed. The management of primary tracheal tumors may often require surgical resection or rigid bronchoscopy which entail their own risks. We present the management of a 90% obstructing tracheal schwannoma via a minimally invasive approach using a bronchoscope passed through a laryngeal mask airway (LMA) with the assistance of a CO2 laser and wire loop
METHODS: Patient was ventilated with an LMA while under general anesthesia. Upon inspection with the flexible bronchoscope, the mass appeared to be a heterogeneously lobulated soft tissue mass occluding nearly the entire lumen and oscillating on a pedicle. We first utilized a CO2 laser to free the mass from the wall and achieve hemostasis. We then placed the patient in Trendelenburg and the mass was captured with a wire loop and removed simultaneously with the LMA due to its size.
RESULTS: A 3.7 cm x 1.9 cm x 1.6 cm mass was removed from the tracheal lumen. Pathology showed the mass to be composed of spindle cells consistent with the diagnosis of schwannoma. The patient tolerated the procedure well and was discharged home from the recovery room the day of surgery.
CONCLUSIONS: This patient presented late with a tracheal mass occluding over 90% of his airway for which he had attributed his symptoms to asthma for years. Management of large, nearly occlusive tracheal masses can be challenging with regards to the best approach and depends on the size, location, and character of the mass. When a benign mass is suspected or proven in a location accessible via bronchoscopy, we prefer to start with a flexible bronchoscope to assess the mass. Pre-operative CT is invaluable in delineating macroscopic detail and defining nearby structures. In this case, the patient’s tumor was pedunculated from the lateral tracheal wall and occluding >90% of the airway. The mass was freed from its tracheal attachment with a flexible bronchoscope using CO2 lasering before being withdrawn from the airway with a loop wire.
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