Delayed Repair of Bronchial Avulsion in a Child through Median Sternotomy

Abstract

A 3-year-old girl presented with blunt compression injury to the thorax. Her left lung was initially aerated and she appeared to recover after right pleural cavity tube drainage alone. She presented 4 months later with a total white-out of the left lung; avulsion of the left main bronchus was diagnosed and repaired successfully. The diagnosis of bronchial injury was missed initially, as the initial pneumothorax was contralateral and the ipsilateral lung remained aerated despite complete bronchial disruption. The traditional surgical approach for these injuries has been lateral thoracotomy for both emergency and later repair; however, median sternotomy afforded excellent exposure for elective repair. CASE REPORTA 3-year-old girl sustained a compression injury to her chest when a water boiler fell on top of her. On arrival, she was fully conscious and hemodynamically stable but with noisy respiratory distress and extensive surgical emphysema of the neck and right anterior chest wall and decreased air entry over the right hemithorax. The initial chest radiograph revealed a right hemopneumothorax and pneumomediastinum ( Fig. 1). A right-sided intercostal drain was inserted, with reexpansion of the right lung and resolution of the surgical emphysema. The drain was removed 2 days later and she was discharged from the hospital apparently well. Four months later, she presented complaining of persistent dyspnea, malaise, and a nonproductive cough. Chest radiography showed a white-out on the left (Fig. 2) and a computed tomographic scan confirmed complete left pulmonary atelectasis. Bronchoscopy revealed total occlusion of the origin of the left main bronchus flush with the carina. Through a median sternotomy, the carina was exposed and the origin of the left main bronchus was found distracted laterally. The scarred strictures of both ends were excised and the endotracheal tube was advanced into the right main bronchus to allow comfortable reanastomosis after suction of the left bronchial tree. Anastomosis was with interrupted 4-0 polydioxanone sutures, with all knots placed extraluminally. Ventilatory support was required for 9 days and the left lung reexpanded gradually. When reviewed after 3 months, the child was well and the left lung was fully expanded (Fig. 3). DISCUSSIONThoracic injury is the second leading cause of death after childhood trauma, and the presence of thoracic injury in addition to other injuries in a child increases the probability of death three to four times. 1 The pliability of the chest wall in children allows transmission of massive external forces without disrupting the integrity of the chest wall. Significant intrathoracic injuries such as major pulmonary contusion or tracheobronchial disruption can be present with little external evidence of injury; 2 therefore, a high index of suspicion must be maintained to diagnose serious injury. Mortality rates of up to 30% have been reported for children with tracheobronchial rupture, and approximately half of children who die as a result of this injury ...

Delayed Presentation and Treatment of Tracheobronchial Injuries Due to Blunt Trauma

“…[5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] The median time from initial injury to presentation was 6 months. The earliest return to the hospital was 2 weeks after the initial injury, and 2 cases were delayed 20 years.…”

Complete transection of bilateral main bronchus in a 5-year-old: A case report

“…Delayed diagnosis is de ned as a de nite diagnosis more than 48 hours after injury and is common in patients transferred from surrounding hospitals [10] ; 25%-68% of patients are not diagnosed with tracheal injury within this time [11] . A delay in diagnosis results in scar tissue and obstruction of the bronchus by granulation tissue [12] .…”

Preserving lung after traumatic transection of left lower lobe bronchus from bullet injury

“…If the diagnosis of bronchial injury is delayed then it is better to approach by median sternotomy instead of the thoracotomy for a better visualisation 9. In this case, the difficulty of surgery was compounded by the awkward anatomical location for the anastomosis; however, we were able to avoid resection by re-implanting the shattered bronchus and ensuring success by meticulous follow-up and regular fibre-optic bronchoscopic washing which was necessary because anastomotic site oedema leads to plugging of secretions and clots draining from the distal lobe.…”