SS. Kho*a (Dr), MZ. Nasaruddina (Dr), JL. Wana (Dr), MF. Abu Samana (Dr), JA. Abdul Rahamana (Dr)

a Department of Pulmonology, Serdang Hospital, Selangor, MALAYSIA

* bzk99@hotmail.com

Background Airway involvement in post-tuberculosis tracheobronchial stenosis (PTTS) is frequently complex in nature with multi-level involvement. Airway recanalization attempt is extremely challenging in patients who present late with chronic total occlusion (CTO) of the main bronchi with no visible ostium. Frequently, such patients will be managed conservatively if surgical reconstruction is deemed unsuitable.

Case Report An 18-year-old lady with a history of pulmonary tuberculosis presented with recurrent pneumonia. Flexible bronchoscopy noted distorted trachea with multi-level tracheobronchial stenosis with no visualisation of RMB ostium. Primary surgical repair was deemed high risk in view of the complexity of stenosis. Under rigid bronchoscopy, the RMB ostium was first postulated by observing the pattern of mucosal indentation and puckering but was proven inaccurate after verification by virtual bronchoscopic navigation (VBN). After establishing a safety margin using convex probe endobronchial ultrasound at the proposed RMB ostium, the area of interest was then punctured with a 20G transbronchial aspiration needle (TBNA) followed by passing of guidewire under fluoroscopic guidance. The puncture was successful after purulent secretion was seen flowing through the TBNA needle as well as swift advancement of guidewire into the right endobronchial tree. Mucosal incision was then performed with electrocautery knife in a radial manner. The incised ostium was then gradually dilated from 4 to 8mm employing the controlled radial expansion (CRE) balloon. The neo-RMB ostium was then treated with topical mitomycin C after bronchoscopic examination confirmed normal distal airway. Procedure was uncomplicated and RMB remain patent on fourth month of surveillance bronchoscopy with significant improvement of total lung capacity from 2.36 to 3.63 liter.

Conclusion This case highlights the importance of diligent pre-procedural planning coupled with a combination of various interventional pulmonology techniques to provide a safe and novel approach to this complex and challenging, century-old problem.

Disclosure of funding source(s): none