Bilateral Partial Bronchial Obstruction due to Broncholithiasis Treated With Laser Therapy

Abstract

The previously recognized modes of therapy for symptomatic broncholithiasis are broncholithectomy via surgery or bronchoscopy. A 46-year-old woman with bilateral partial bronchial obstruction was treated with Nd-YAG laser with complete resolution of symptoms and of airway obstruction. The previously recognized modes of therapy for symptomatic broncholithiasis are broncholithectomy via surgery or bronchoscopy. A 46-year-old woman with bilateral partial bronchial obstruction was treated with Nd-YAG laser with complete resolution of symptoms and of airway obstruction. Broncholithiasis is defined as the presence of calcified material within the bronchial lumen or compressing the tracheobronchial tree. The usual presenting symptoms are cough, hemoptysis, purulent sputum, fever, chest pain, dyspnea, and wheezing. Although lithoptysis is pathognomonic for broncholithiasis, it is rarely seen. Not all eases of broncholithiasis require treatment. However, if symptoms persist or if a bronchoesophageal or a bronchoarterial fistula or malignant tumor is suspected, intervention is necessary, either by removal of the broncholith through bronchoscopy, which remains controversial, or through surgical resection. A 46-year-old female bus driver with a history of allergic rhinitis for 22 years was referred for evaluation of wheezing, cough productive of clear sputum, and exertional dyspnea for 6 months prior to her visit. She also reported recently expectorating two small stones that were 1 to 2 mm in diameter. Her medical history disclosed anemia. Her physical examination revealed scattered wheezing throughout both lung fields with a prolonged expiratory phase but was otherwise normal. The chest x-ray film and a CT scan of the thorax revealed bilateral perihilar adenopathy with calcification (Fig 1). Values for the remainder of her laboratory studies were within normal ranges except for a hemoglobin level of 8.6 g/dL, which was determined to be secondary to heavy menses. A purified protein derivative skin test and histoplasma antibody titers were negative. Pulmonary function testing showed moderate obstructive disease with an FVC of 3.3 L and FEV1 of 1.9 L. The patient reported that she had a pet parakeet for 5 years as a child and also noted some exposure to chickens, ducks, and pigeons. She denied travel to the San Joaquin or Mississippi River valleys. The patient's respiratory symptoms improved after therapy with prednisone, inhaled albuterol, and inhaled beclomethasone, but 6 months later she reported a recurrence of wheezing and productive cough as well as hemoptysis and lithoptysis. Flexible fiberoptic bronchoscopy demonstrated pedunculated granulation tissue in the left mainstem bronchus partially obstructing the lumen as well as a similar lesion in the intermediate bronchus (Figs 2 and 3). Biopsy of these lesions showed only granulation tissue with inflammatory and epithelial cells. It was concluded that the patient's symptoms were caused by bilateral broncholithiasis possibly as a result of prior exposure to Histoplasma capsulatum although this could not be conclusively determined. Nd-YAG laser photoradiation therapy was chosen for coagulation of the granulation tissue. This treatment was performed with a fiberoptic bronchoscope (Olympus BF 1T10) with the patient receiving local anesthesia and conscious sedation. Both masses were removed and further laser coagulation was applied to the stalk and the area of insertion at the bronchial wall level. At this point, there was no evidence of calcifications at the treatment zone. As a result of this single procedure, the patient experienced complete resolution of her respiratory symptoms. Subsequent review bronchoscopy failed to demonstrate recurrence of the obstructing granulation tissue (Figs 4 and 5) in the following 4 years. Spirometric values returned to normal while the patient remained asymptomatic.3Granulation tissue partially obstructing the intrabronchial lumen, right bronchial tree.View Large Image Figure ViewerDownload (PPT)4Complete resolution of the partial obstruction of the left bronchial tree after laser therapy.View Large Image Figure ViewerDownload (PPT)5Complete resolution of the partial obstruction of the right bronchial tree after laser therapy.View Large Image Figure ViewerDownload (PPT) Broncholithiasis is a rare disease. Most commonly, it is caused by a calcified hilar or peribronchial lymph node eroding into the tracheobronchial tree. Respiratory movements cause their migration into the bronchus and induce pressure atrophy of the bronchial wall, and as a result of this process, erosion and obstruction of the intrabronchial lumen takes place.1Faber LP Jensik RJ Chawla SK et al.The surgical implication of broncholithiasis.J Thorac Cardiovasc Surg. 1975; 70: 779-789Abstract Full Text PDF PubMed Google Scholar Calcification of the lymph nodes occurs frequently as a result of tuberculosis or histoplasmosis2Cole FH Cole Jr, FH Khandekar A et al.Management of broncholithiasis: is thoracotomy necessary?.Ann Thorac Surg. 1986; 42: 255-257Abstract Full Text PDF PubMed Scopus (40) Google Scholar, 3Dixon GF Donnenberg RL Schonfeld SA et al.Advances in the diagnosis and treatment of broncholithiasis.Am Rev Respir Dis. 1984; 129: 1028-1030PubMed Google Scholar but can occur secondary to other disorders including silicosis.3Dixon GF Donnenberg RL Schonfeld SA et al.Advances in the diagnosis and treatment of broncholithiasis.Am Rev Respir Dis. 1984; 129: 1028-1030PubMed Google Scholar However, broncholithiasis also can be caused by calcification of aspirated food or tissue or as a result of obstruction by calcified bronchial cartilage secondary to necrosis.4Galdermans D Verhaert J Van Meerbeeck J et al.Broncholithiasis: present clinical spectrum.Respir Med. 1990; 84: 155-156Abstract Full Text PDF PubMed Scopus (13) Google Scholar Broncholithiasis has a predilection for the right bronchial tree but shows no predilection for either sex and may occur in patients of any age. The diagnosis of broncholithiasis is established in virtually 100% of cases using the combined modalities of a CT scan and flexible fiberoptic bronchoscopy. The optimal treatment of broncholithiasis is controversial. Two therapeutic approaches utilized at present are surgical resection and removal of the broncholith by bronchoscopy. Several authors2Cole FH Cole Jr, FH Khandekar A et al.Management of broncholithiasis: is thoracotomy necessary?.Ann Thorac Surg. 1986; 42: 255-257Abstract Full Text PDF PubMed Scopus (40) Google Scholar, 3Dixon GF Donnenberg RL Schonfeld SA et al.Advances in the diagnosis and treatment of broncholithiasis.Am Rev Respir Dis. 1984; 129: 1028-1030PubMed Google Scholar, 5Arrigoni MG Bernatz PE Donoghue FE Broncholithiasis.J Thorac Cardiovasc Surg. 1971; 62: 231-237Abstract Full Text PDF PubMed Google Scholar have argued that endoscopic stone removal, preferably by rigid bronchoscopy, can be attempted if no complications of stone erosion like massive hemoptysis, fistulas, lung abscesses, or bronchiectases are present, especially if the broncholith is loose and mobile within the bronchial lumen. Other authors1Faber LP Jensik RJ Chawla SK et al.The surgical implication of broncholithiasis.J Thorac Cardiovasc Surg. 1975; 70: 779-789Abstract Full Text PDF PubMed Google Scholar, 6Igoe D Lynch V McNicholas WT Broncholithiasis: bronchoscopic versus surgical management.Respir Med. 1990; 84: 163-165Abstract Full Text PDF PubMed Scopus (12) Google Scholar argue that given the risk of pulmonary artery erosion by the broncholith, even when minimal hemoptysis is present, surgical intervention should be the procedure of choice. Surgical procedures range from simple removal of the broncholith through thoracotomy to lobectomy, with conservation of as much pulmonary tissue as possible. With the latter procedure, resection of all the tissue affected by broncholithiasis is performed. Laser therapy, as an alternative, can provide the benefits of endoscopic removal, including the avoidance of general anesthesia and the morbidity associated with thoracotomy. Laser therapy allows minimal patient discomfort following removal and allows avoidance of hospitalization. Additionally, the possibility of hemorrhage from the pulmonary artery or one of its branches is significantly reduced by coagulation of endobronchial tissue around the broncholith. Removal of the bronchial part of the broncholith should be avoided. However, in cases where a significant part of the stone protrudes into the lumen with risk of obstruction or irritation of other parts of the bronchial tree, laser techniques can be used to shatter the stone. The shattering effect is achieved by applying high laser power (80 to 100 W to the smallest surface area) and very short pulses (0.2 to 0.3 s) interspaced by rest periods (2 to 5 s) to avoid overheating of the broncholith and the adjacent tissues. In the case reported here, the treatment of broncholithiasis was limited to removal of the endobronchial granulation tissue. The broncholith remains in place. Selected patients whose symptoms are due to obstruction by reactive tissue from the underlying broncholith can benefit from palliative Nd-YAG laser photocoagulation therapy as an alternative to more invasive thoracotomy.