Carinal resection for stenotic tuberculous tracheitis.

An 18 year old Chinese woman presented in March 1986 with a one month history of increasing wheeze and dyspnoea during exertion. She had been treated elsewhere for pulmonary tuberculosis since November 1985 but admitted poor compliance with treatment. Physical examination showed a very apprehensive woman with inspiratory stridor and cyanosis. A chest radiograph showed mild disease of the right upper lobe compatible with pulmonary tuberculosis. Her respiratory state deteriorated rapidly and endotracheal intubation was attempted without success. An emergency tracheostomy under local anaesthesia also failed as a tracheostomy tube could not be passed. Tracheal stenosis was suspected and a bronchoscopy arranged. The patient was semiconscious and cyanosed. Ventilation was maintained with difficulty by means of a Sander's injector through a partly inserted tracheostomy tube. Blood gas analysis showed pH 6-96, carbon dioxide tension (Pco2) 14-1 kPa, and oxygen tension (Po2) 19-6 kPa. Rigid bronchoscopy disclosed a tight stenosis of 2-3 mm diameter about 5 cm below the tracheostomy site. Repeated dilatations using gum elastic bougies improved ventilation but an endotracheal tube still could not be inserted transorally. Satisfactory ventilation was obtained with a 4 5 mm portex endotracheal tube inserted via the tracheostomy and pushed past the stenotic segment. At this stage pH was 7 4, Pco2 62 kPa, and Po2 58 3 kPa. There was difficulty in maintaining the tube in position and a decision was made to resect the stenosed segment ofthe trachea. A right sided lateral thoracotomy showed a collapsed upper lobe and mild inflammatory changes around the lower trachea with an apparently normal external diameter. An upper lobe bronchotomy resulted in the expulsion of necrotic material. A fibreoptic bronchoscope inserted via the bronchotomy and advanced retrogradely into the trachea defined the lower limit of the stricture as being 2 cm above the carina. The stenosed segment of trachea, consisting of five rings, was excised and an end to end anastomosis made.2 Ventilation during surgery was maintained via a 7 mm endotracheal tube introduced directly