Removal of an inhaled stoma button distal to a reactionary tracheal stenosis: a difficult airway case.

We present the complex and rare case of an inhaled stoma button causing proximal tracheal stenosis in a laryngectomy patient. The patient was unaware he had inhaled his button and presented with increasing shortness of breath and noisy breathing. In this case we discuss the challenging management of the stenotic tracheal segment above the impacted stoma button and the surgical approach to this difficult airway. The distal foreign body was safely removed using rigid bronchoscopy and balloon dilatation. This difficult airway required multidisciplinary input from the ENT, cardiothoracic and anaesthetic teams.

Delayed diagnosis of chronic postoperative sternal infection: a rare case of sternal tuberculosis.

Sternal osteomyelitis secondary to mycobacterium tuberculosis (TB) is rare, with <1% of musculoskeletal TB cases reported. The recurrent scenario is unresolving infection and delayed diagnosis. A 75-year-old woman presented with a persistently discharging sternal wound 10 months after coronary artery bypass grafting. Multiple antibiotics, wound debridement and removal of sternal wires was attempted; however, progression to local osteomyelitis and sternoclavicular joint destruction occurred. Tissue biopsies were finally sent for mycobacterial culture testing positive for Mycobacterium tuberculosis High index of suspicion is necessary for diagnosis of sternal tuberculosis, confirmed through timely microbiological investigations. MRI may identify soft-tissue and bone oedema characteristic of TB osteomyelitis. This patient had no TB risk factors. The source of infection is unclear and warrants further investigation. Sternal TB osteomyelitis is uncommon and largely reported through case reports, thus management and indications for surgery remain undefined. If sensitive, standard TB four-drug regimen may be trialled.

Endobronchial laser ablation in the management of epithelial-myoepithelial carcinoma of the trachea.

A 52 year old, never smoker presented to hospital with progressive shortness of breath and significant stridor over a five month period. He also described the feeling of needing to cough but being unable to expectorate. CT Thorax demonstrated a mass lesion in the trachea just distal to the larynx which was then confirmed on rigid bronchoscopy. Subsequent histology confirmed an epithelial-myoepithelial carcinoma. Only a few case reports document these rare salivary gland tumours occurring in other locations such as the respiratory tract. After staging showed only local disease, the patient was managed with rigid bronchoscopy and laser ablation therapy. We present the first documented case to be treated with endobronchial laser ablation therapy with discussion of the incidence, presentation and characteristics of these tumours including the treatment options, as well as the use of laser ablation in the management of benign and malignant endobronchial lesions.

A 15-cm aneurysm of the right coronary artery presenting as a pericardial cyst.

We report an unusual case of a giant right coronary artery aneurysm, measuring 15 cm in diameter, in a 76-year old woman. The aneurysm was initially identified when the patient was investigated for signs of congestive cardiac failure with a computed tomography scan of her thorax; at this stage, the lesion was misdiagnosed as a large pericardial cyst. The aneurysm was successfully excised at surgery and her heavily diseased right coronary artery was secured with a saphenous vein graft.

Concomitant mitral valve surgery with aortic valve replacement: a 21-year experience with a single mechanical prosthesis.

BACKGROUND: Long-term survival for combined aortic and mitral valve replacement appears to be determined by the mitral valve prosthesis from our previous studies. This 21-year retrospective study assess long-term outcome and durability of aortic valve replacement (AVR) with either concomitant mitral valve replacement (MVR) or mitral valve repair (MVrep). We consider only a single mechanical prosthesis. METHODS: Three hundred and sixteen patients underwent double valve replacement (DVR) (n = 273) or AVR+MVrep (n = 43), in the period 1977 to 1997. Follow up of 100% was achieved via telephone questionnaire and review of patients' medical records. Actuarial analysis of long-term survival was determined by Kaplan-Meier method. The Cox regression model was used to evaluate potential predictors of mortality. RESULTS: There were seventeen cases (5.4%) of early mortality and ninety-six cases of late mortality. Fifteen-year survival was similar in both groups at 44% and 57% for DVR and AVR+MVrep respectively. There were no significant differences in valve related deaths, anticoagulation related complications, or prosthetic valve endocarditis between the groups. There were 6 cases of periprosthetic leak in the DVR group. Sex, pre-operative mitral and aortic valve pathology or previous cardiac surgery did not significantly affect outcome. CONCLUSION: The mitral valve appears to be the determinant of survival following double valve surgery and survival is not significantly influenced by mitral valve repair.

Primary mediastinal synovial sarcoma.

Synovial sarcoma occurs predominantly in the soft tissues of the extremities, but is exceedingly rare in the mediastinum. It has overlapping histological and immunophenotypic features with other tumours in the differential diagnosis. We report a case of a patient who had an incidental finding of such a tumour. Because of the rarity of this tumour in the mediastinum, optimal therapy is unknown and the prognosis remains guarded.