Clinical Presentation

The Big Asthma Lie

Asthma Cure Diet

Get Instant Access

Patients with tracheal tumors commonly have a long history of persistent coughing, which may steadily worsen. A patient notices gradual onset of shortness of breath on exertion, which will progress to dyspnea figure 7-18 Infiltrating spindle cell sarcoma with myxoid stroma, involving the lower trachea (T), carina, and much of the left main bronchus (Lt), in a 28-year-old man. Carinal resection and left pneumonectomy were followed by 6,000 cGy irradiation and chemotherapy. The hook in the gross specimen is at the carina. The patient died 3 years later of tumor progression.

figure 7-18 Infiltrating spindle cell sarcoma with myxoid stroma, involving the lower trachea (T), carina, and much of the left main bronchus (Lt), in a 28-year-old man. Carinal resection and left pneumonectomy were followed by 6,000 cGy irradiation and chemotherapy. The hook in the gross specimen is at the carina. The patient died 3 years later of tumor progression.

at rest. At this point, the airway is reduced to 30 to 50% of its normal cross-sectional area. Dyspnea may be aggravated by eating and by position. Wheeze is followed by true stridor (Table 7-3).79 Chest roentgenograms are frequently interpreted as normal on the basis of clear lung fields, although the lesion may well be visible if the tracheal air column is examined critically. Unfortunately, a radiologist's index of suspicion of a tumor in the presence of such symptoms is all too often no greater than that of a pulmonologist or thoracic surgeon. In a patient with signs of upper airway obstruction—dyspnea on exertion, wheeze, or stridor, with or without cough—organic obstruction of the upper airway should be suspected, even if the lung fields appear to be clear on standard roentgenograms. The patients are all too often treated for "adult onset asthma" or for other imprecise diagnoses for long periods of time. Some present with Cushingoid appearance due to prolonged administration of high-dose steroids for treatment of presumed asthma. Such patients should be bronchoscoped early. A benefit of increasing use of computed tomography (CT) scans is earlier identification of tracheobronchial lesions.

Hemoptysis occurs sooner or later with many tumors, especially epithelial. It is more common with SCC of the trachea, somewhat less common with ACC and carcinoid tumors, and may not occur at all with many tumors, especially of mesenchymal origin, benign or malignant. Since the warning sign of hemoptysis is less frequent in ACC than in SCC (Table 7-4), the duration of symptoms is usually longer in the former and wheeze has more often developed.6 As expected, resectability diminishes in patients with a longer average duration of symptoms prior to diagnosis in both types of carcinomas (Table 7-5). Hemoptysis mandates bronchoscopy, even with apparently clear lung fields radiologically, and is explained away distressingly often as due to strenuous cough, tracheobronchitis, or pneumonia. The bronchoscopist must think of the possibility of tracheal tumor. In particular, if the tumor is in the upper trachea, the bronchoscopist, even with a flexible bronchoscope, may pass too quickly from the vocal cords to a supracarinal, carinal, and bronchial examination and overlook a small proximal tracheal lesion. If examination is made with the flexible bronchoscope through an endotracheal tube, the tube must be withdrawn to the level of the glottis as the examination is completed so that the entire trachea is visualized.

Unilateral or bilateral pneumonitis may occur. Episodes of pneumonia or pneumonitis may respond to treatment, only to recur. Recurrent pneumonia or persisting pulmonary infiltrates, particularly in an otherwise healthy patient, are indications for bronchoscopy. A small tumor low in the trachea may produce recurrent unilateral pneumonitis and yet be of such small size that it is not visualized on tomography. A thin-section CT scan, however, will demonstrate even tiny tracheobronchial lesions. Hoarseness results

Table 7-3 Symptoms and Signs Associated with Tracheal Tumors

Number from 84 Patients

Dyspnea 44

Hemoptysis 28

Cough 22

Wheezing 16

Dysphagia 13

Change in voice and/or hoarseness 13*

Stridor 12

Pneumonia 10

Emphysema and/or asthma 9

Adapted from Weber AL and Grillo HC.79

*Eight of 13 had vocal cord paralysis.

Table 7-4 Comparative Symptoms in Adenoid Cystic Carcinoma (ACC) and Squamous Cell Carcinoma (SCC) of Trachea

Number from 135 Patients of each Diagnosis

Table 7-4 Comparative Symptoms in Adenoid Cystic Carcinoma (ACC) and Squamous Cell Carcinoma (SCC) of Trachea

Number from 135 Patients of each Diagnosis

Was this article helpful?

0 0
Dealing With Asthma Naturally

Dealing With Asthma Naturally

Do You Suffer From ASTHMA Chronic asthma is a paralyzing, suffocating and socially isolating condition that can cause anxiety that can trigger even more attacks. Before you know it you are caught in a vicious cycle Put an end to the dependence on inhalers, buying expensive prescription drugs and avoidance of allergenic situations and animals. Get control of your life again and Deal With Asthma Naturally

Get My Free Ebook


Post a comment