대한흉부영상의학회 Weekly Chest Cases

Case No : 801 Date 2013-03-04

Courtesy of Hee Young Lee, Ho Yun Lee / Samsung Medical Center
Age/Sex 47 / F
Chief Complainttraffic accident a week ago

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initial chest radiograph

Diagnosis With Brief Discussion

Diagnosis: Traumatic Bronchial Rupture
Radiologic Findings: Initial chest radiograph shows a total haziness in the left lung and abrupt cut off the left main bronchus with a small amount of residual pneumothorax despite a well-placed chest tube. Follow-up chest radiograph obtained 2 weeks later shows persistent pneumothorax despite a well-placed chest tube which suggests the diagnosis of bronchial rupture. Contrast enhanced CT scans show multiple rib fracture in the left hemithorax and subcutaneous emphysema. Obliteration and discontinuity of left main bronchus with atelectasis of the entire left lung confirms the diagnosis of traumatic bronchial rupture. The patient underwent segmental resection and anastomosis of left main bronchus without any complication.
Brief Review: Traumatic Tracheal or Bronchial Rupture
-Resulting from penetrating injury or intubation, blunt trauma, high-speed traffic accidents
Tracheobronchial injuries affect 3% of all patients who sustain blunt chest trauma. 80% of intrathoracic tracheobronchial injuries are within 2.5 cm of the carina, most commonly involving the proximal right main stem bronchus. 80% of these patients die within 2 hr from associated injuries. Findings of airway rupture are sometimes subtle and may be overshadowed by the other injury.
50 to 100% of patients who sustain blunt tracheobronchial injuries have major associated injuries, including esophageal perforation in up to 20%. The most frequent symptoms of all blunt airway injuries are dyspnea (76 to 100%) and hoarseness (46%).
Chest radiography
- Pneumomediastinum(60%)
- Pneumothorax (up to 70%)
- Coexistence of pneumothorax and pneumomediastinum; strongest indication of a bronchial rupture
- persistant pneumothorax with a large air leak despite a well-placed chest tube
- in the case of complete transsection, the fallen lung sign of Kumpe
- overdistention of endotracheal tube cuff, displacement of endotracheal tube
CT is indicated in the stable patient for the evaluation of possible associated injuries. An unrevealing CT scan does not obviate bronchoscopy if intrathoracic tracheal rupture is suspected. The presence of significant air leak alone is sufficient to mandate bronchoscopy without the need for advanced imaging.
The diagnosis of bronchial rupture depends on awareness of this possibility of severe thoracic trauma.
Primary airway repair is usually possible, except when there is significant destruction, in which case resection and reanastomosis should be performed. A small proportion of patients present in a delayed fashion, usually within 4 weeks of injury, with hemoptysis, pneumonitis, or both, complicating an obstructed airway. Only rarely do patients present with a healed airway injury years later, typically with dyspnea or the diagnosis of asthma.
References: 1. Wan YL, Tsai KT, Yeow KM, Tan CF, Wong HF. CT findings of bronchial transection. Am J Emerg Med 1997;15:176-7
2. Tack D, Defrance P, Delcour C, Gevenois PA. The CT fallen-lung sign. Eur Radiol 2000;10:719-21
3. Karmy-Jones R, Avansino J, Stern EJ. CT of blunt tracheal rupture. AJR Am J Roentgenol 2003;180:1670
4. Zhao Y, Jiao J, Shan Z, et al. Effective management of main bronchial rupture in patients with chest trauma. Thorac Cardiovasc Surg 2007;55:447-9
Keywords: Airway, Trauma, Tracheal abnormality,

No. of Applicants : 80

▶ Correct Answer : 25/80, 31.3%

- Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
- GHICL , France manuel toledano
- McGill University Health Center , Canada Alexandre Semionov
- University of British Columbia , Canada Amr Ajlan
- Asan Medical Center , Korea (South) Sang Min Lee
- Dongnam Institute of Radiological and Medical Sciences , Korea (South) Dae-Wook Yeh
- Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
- phc mararikulam , India rikhy krishnan
- Seoul Asan Medical center , Korea (South) Ji-Won Kang
- Hospital do Servidor Publico Estadual , Brazil Sasaki
- GM InHospital , Korea (South) Ju Won Lee
- Seoul university hospital , Korea (South) Youngjin Ryu
- Himchan Hospital kangbuk , Korea (South) Kwon Hyoung Kim
- Kyungpook National University Hospital , Korea (South) Jaekwang Lim
- clinique de SAVOIE , France, Metropolitan gay-depassier philippe
- CHU Poitiers , France CHAN paul
- Myongji hostipal , Korea (South) Yongsuk Jang
- IRSA La Rochelle France , France Denis Chabassiere
- IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
- CAC Rennes , France nicolas gautier
- Fortis hospital , Mohali , India Shaleen Rana
- All India Institute of medical sciences , India Justin Moses
- Ishikawa Matto Central Hospital , Japan Manabu Akimoto
- XiangYa hospital , China Xia Yu
- NIMS, HYDERABAD , India bhaskar kakarla

▶ Correct Answer as Differential Diagnosis : 6/80, 7.5%

- jaslok hospital & research centre mumbai , India JAINENDRA JAIN
- SNUH , Korea (South) Euijin Hwang
- Kizawa Memorial Hospital , Japan Yo Kaneko
- Hanyang Medical Center , Korea (South) Kibo Yoon
- McGill university , Canada Badriya Al-Qassabi
- Medicheck health care , Korea (South) Chae Lim

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 801 Date 2013-03-04

Discussion

No. of Applicants : 80