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1418 Part Two: Surgical Practice
A B
Tracheostoma
include resection for localized involvement, tracheoplasty, or
stenting.72,73 Airway stents can be divided into two groups, sil-
icone and metal, with each type having distinct advantages
(Table 80.8). Silicone stents require rigid bronchoscopy to
place, have a narrower inner lumen, and are more easily dis-
placed. Advantages to the use of silicone stents are that they
are easily adjustable or removable, they do not develop tissue
ingrowth, and they are nonreactive to the endoluminal lining.
Metal stents can be placed by flexible bronchoscopy and con-
form to the trachea better. They are permanent and difficult to
adjust. Placement requires fluoroscopy, and granulation tissue
often grows in between metal struts making subsequent
FIGURE 80.33. Management of tracheoinnomi-
nate artery fistula. A: Common mechanism of
injury from erosion of innominate artery by adja-
cent tracheostomy tube. B: Emergency treatment of
hemorrhage involves insertion of an endotracheal
tube into the tracheostomy stoma, inflation of the
cuff, and downward and outward pressure on the
fistula by the finger inserted through the tra-
cheostomy incision to further tamponade the bleed-
ing. C: Through a partial upper sternal split, the
segment of involved innominate artery is resected
and the oversewn ends covered with adjacent medi-
astinal fat or muscle. Tracheal resection is usually
not necessary. A new tracheostomy tube may have
to be inserted higher in the trachea or, if possible,
the tracheostomy tube removed and the stoma cov-
ered with a sternohyoid muscle flap.
removal difficult.70 Newer stents being developed include cov-
ered metal stents that prevent tumor ingrowth along the stent,
but unfortunately still allow granulation tissue to grow in at
the ends.74 In addition to being useful in the setting of tracheal
stenosis, they can also play an essential role in palliating post-
transplant bronchial stenosis.75
MEDIASTINUM
The mediastinum contains several important structures and
may be involved in different disease processes. Mediastinal
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Chapter 80: Chest Wall, Pleura, Mediastinum, and Nonneoplastic Lung Disease 1419

Central Airway Tumor with

Symptomatic Obstruction

Unresectable Resectable

Surgery
Endoluminal Extrinsic
tumor compression

Core-out Stent
Laser PDT
etc.

Recurrent
Disease?

ALGORITHM 80.5

ALGORITHM 80.5. Algorithm for management of tracheal masses. (Adapted from Wood DE. Surg Clin North Am 2002;82(3):621–642).

infections are not as common as they were in the past, but The posterior compartment includes the esophagus, sympa-
when they present, they are life-threatening situations. The thetic chain, and vertebral column (Fig. 80.36). Most lesions
mediastinum is divided into several compartments, including are found in asymptomatic patients, but presenting symp-

the superior, anterior, middle, and posterior regions. Some-
times the lower three compartments are extended superiorly
and only three are described (Fig. 80.35). The anterior medi-
astinum includes the fat and lymph nodes posterior to the
sternum but anterior to the pericardium. The middle com-
partment includes the pericardium, heart, aorta, and trachea.
LUNG
toms include dyspnea and chest pain. Symptoms may be
local, related to compression on mediastinal structures, or
systemic, caused by the release of cytokines or inflammatory
factors, such as in lymphomas or thymomas with myasthe-
nia gravis. Imaging begins with plain radiographs, but CT
scans are essential. MRI scans may be helpful to evaluate

FIGURE 80.34. Diagrams of principal postintubation tracheal lesions. A: Cuff stenosis from
the cuff of an endotracheal tube. B: Cuff stenosis from the cuff of a tracheostomy tube, usually
lower in the trachea than that from an endotracheal tube. Stomal stenosis also occurs at the site
of the tracheostomy itself. Malacia may occur either at the level of the cuff or in the segment
between the stoma and the cuff stenosis. C: Cuff stenosis at the site of a high tracheostomy
stoma, which has eroded into the lower margin of the cricoid cartilage. In older patients, this
may erode back farther into the subglottic larynx, producing a laryngotracheal stenosis. A
stoma placed in the cricothyroid membrane will, by definition, produce an intralaryngeal steno-
sis. D: Tracheoesophageal fistula (TEF) produced by pressure of the cuff against the “party
wall,” often abetted by an indwelling firm nasogastric tube. E: One type of tracheoinnominate
fistula (TIF) as the result of a high-pressure cuff erosion. The more common type, but also rare,
is that seen with a low-placed tracheostomy stoma, which rests against the innominate artery
itself. (Reproduced with permission from Grillo HC. Surgical treatment of postintubation tra-
cheal injuries. J Thorac Cardiovasc Surg 1979;78:860–875.)
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1420 Part Two: Surgical Practice

TA B L E 8 0 . 8 arise from the thymus gland and can be seen with autoimmune
diseases such as myasthenia gravis (MG) and pure red cell apla-
CLASSIFICATION OF AIRWAY STENTS sia. Tumors are usually classified by the Masaoka classification
system (Table 80.10), which looks at gross and microscopic
■ Silicone stents spread of the tumor, or the World Health Organization
Advantages (WHO) histologic criteria, which is based on the morphology
Adjustable of the epithelial cells as well as the lymphocyte-to–epithelial
Removable cell ratio. Diagnosis is usually made by chest CT scan. Needle
Minimal Granulation biopsy of a potential thymoma is not routinely recommended
Disadvantages for fear of seeding the needle track. When thymomas are sus-
Gen. Anesthesia/Rigid bronch to place pected, resection is the best option, via a midline sternotomy
Migrates (Fig. 80.37) Resection must take care to remove all of the tis-
Secretions adhere to stent sue in the anterior compartment, including all fat and tissue
Interferes with ciliary clearance around the innominate vein. Entering the pleura should be
Smaller inner diameter avoided if possible to minimize drop metastases into either
■ Metal stents pleural space.
Advantages Thoracoscopic approaches to resect thymomas have been
Less migration described, but some surgeons question this approach due to the
Larger inner diameter potential increased risk of drop metastases, and thus the potential
Less ciliary interference for a poorer oncologic outcome. Neoadjuvant chemotherapy
Flexible bronch to place and radiation may be used to downstage Masaoka III and IV
Disadvantages stage tumors and allow for subsequent resection. Postoperative
May need balloon dilation radiation is recommended for Masoaka stage III tumors,
Difficult to remove and may be considered for stage II disease. Platinum-based
Granulation and tumor ingrowth in the stent chemotherapy is typically used in the unresectable setting.77
Radial force may lead to necrosis/fistula Patients with MG present with diplopia, ptosis, fatigue, and
weakness. One-third to one half of patients with thymomas have
MG, but only 10% of patients with MG have thymomas.
Anti–acetylcholine receptor antibody levels may be measured to
vascular or spinal involvement. PET scans are increasingly evaluate for MG in patients with suspected thymomas.78 Thymic
used as they may further aid in staging. Biopsy and/or sur- carcinomas and thymic carcinoids are other tumor types that can
gical resection is required to confirm the diagnosis in almost also arise from the thymus.
all patients.76 Germ cell tumors can present as benign teratomas, semi-
nomas, and embryonal tumors, which include nonsemino-
matous germ cell tumors and malignant teratomas. Benign
Anterior Mediastinum teratomas have a good prognosis, and resection is the best
treatment. Seminomas constitute up to half of mediastinal
The anterior mediastinum can contain various tumors (Table germ cell malignant tumors. Patients may have symptoms
80.9). Most common are thymomas, lymphomas, and germ from local compression or systemic symptoms such as fever,
cell tumors, in that order. Thymomas account for one fifth of weight loss, and even gynecomastia. These tumors are
all anterior mediastinal masses in the adult population. They radiosensitive, but in locally advanced disease, chemother-

TA B L E 8 0 . 9

LOCATION OF PRIMARY MEDIASTINAL MASSES IN

ADULTS AND CHILDREN

ANTEROSUPERIOR MEDIASTINUM
Thymoma
Lymphoma
Germ cell tumor
Lymphangioma
Hemangioma
Lipoma
Carcinoma
Thyroid adenoma
Parathyroid adenoma
MIDDLE MEDIASTINUM
Pericardial cyst
Bronchogenic cyst
FIGURE 80.35. The mediastinal subdivisions. Note that the paraver- Lymphoma
tebral sulcus encompasses the posterior compartment. (Reproduced POSTERIOR MEDIASTINUM
with permission from Shields TW, ed. General Thoracic Surgery, 6th ed.
2005:Fig. 154–1.) Neurogenic tumor
Enteric cyst
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Chapter 80: Chest Wall, Pleura, Mediastinum, and Nonneoplastic Lung Disease
FIGURE 80.36. Normal mediastinal anatomy as shown with com-
puted tomography scans. A: Scan at level of the aortic arch and midtra-
chea. T, trachea; E, esophagus; AA, aortic arch; SVC, superior vena
cava. B: Scan at level of carina. RULB, right upper-lobe bronchus;
LMB, left mainstem bronchus; AA, ascending aorta; DA, descending
aorta; A, azygos vein; E, esophagus; SVC, superior vena cava; PA, main
pulmonary artery; LPA and RPA, left and right pulmonary arteries. C: Scan
at the level of the left atrium. LA, left atrium; RA, right atrium; LVOT,
left ventricular outflow tract; RV, right ventricle; A, azygos vein; E, esoph-
agus; DA, descending aorta.
apy with later surgical resection is the favored treatment.
Nonseminomatous tumors include a wide variety of histo-
logic malignancies. They usually occur in young men and are
often symptomatic (Fig. 80.38). Elevated alpha-fetal pro-
tein(AFP) and beta-human chorionic gonadotropin (-hCG)
levels are seen with these tumors and should be measured.
Chemotherapy is the best treatment, but patients have a
TA B L E 8 0 . 1 0
MASAOKA STAGING SYSTEM FOR THYMOMA
■ STAGE ■ DEFINITION
I Macroscopically, completely encapsulated;
microscopically, no capsular invasion
IIA Macroscopic invasion in surrounding fatty
tissues or mediastinal pleura
IIB Microscopic invasion into the capsule
III Macroscopic invasion into a neighboring
organ, such as pericardium, great vessels, or
lung
IVA Pleural or pericardial dissemination
IVB Hematogenous or lymphogenous metastases
Adapted from Masaoka A, Monden Y, Nakahara K, et al. Follow-up
study of thymomas with special references to their clinical stages.
Cancer 1981;48:2485, with permission.
1421
LUNG
poorer prognosis when compared to those with seminomas.
Lymphomas in the mediastinum are usually part of a wider
spectrum of disease. Two thirds of cases are Hodgkin disease.
Most patients present with symptoms of fevers, night sweats,
and even weight loss. Treatment is always chemotherapy
based, and surgery in the form of a biopsy is used only to
help make the diagnosis.78
Middle and Posterior Mediastinum
Middle mediastinal masses include esophageal and bron-
chogenic cysts, pericardial cysts, lymphangiomas, and lym-
phomas (Fig. 80.39). For cystic lesions, surgical resection is the
best treatment option. Posterior lesions include neurogenic
tumors, which may be benign or malignant. Almost 95% of
tumors come from the sympathetic chain or intercostal nerve
rami. Up to two thirds of these tumors are benign nerve sheath
tumors and are usually discovered incidentally. An MRI scan
may be used to evaluate intraspinal extension.78
Pediatric Mediastinum
The presentation of mediastinal masses in the pediatric popu-
lation varies from what is observed in adults. The rate of
malignancy is slightly lower in children, and while thymomas
are the most common adult masses seen, neurogenic tumors
are more common in children (Table 80.11). Just over half of
all mediastinal tumors arise in the posterior compartment.79
Anterior masses may include the normal thymus in a young
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1422 Part Two: Surgical Practice

A B

FIGURE 80.37. Thymic resection. (Reproduced with permission from

Scott-Conner CE, Dawson DL, Shirazi MK, et al. Operative Anatomy,
3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008:Fig. 21-3.)
C

TA B L E 8 0 . 1 1 child. Teratomas are the most common germ cell tumor seen.79
Vascular anomalies may be seen in children and include
MEDIASTINAL TUMORS IN CHILDREN hemangiomas and cystic hygromas.80 Middle compartment
tumors are usually foregut cysts, as in the adult population.
■ INCIDENCE REPORTED Posterior tumors are most often malignant neurogenic tumors,
■ TYPE OF TUMOR IN SERIES (%) compared to more benign pathology in adults.79
Neurogenic 35
Lymphoma 25 Mediastinitis
Germ cell 11 9 Mediastinal inflammation can arise from different sources, but
Primary malignancy 2 it is most often infectious in nature. Acute mediastinitis is life
threatening and usually results from a perforated esophagus,
Cysts 25
postcardiac procedure, or trauma. Oral infections can also
result in organisms traveling through the neck into the medi-
From Davis RD Jr, Oldham HN Jr, Sabiston DC Jr. The mediastinum. astinum along fascial planes. These infections can travel as
In: Sabiston DC Jr, Spencer FC, eds. Surgery of the Chest, 5th ed.
Philadelphia: WB Saunders; 1990:507. quickly as necrotizing fasciitis in other parts of the body. A wide
variety of organisms can cause mediastinitis. Patients will have
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Chapter 80: Chest Wall, Pleura, Mediastinum, and Nonneoplastic Lung Disease
FIGURE 80.38. Computed tomography scan of a malignant non-
seminomatous germ cell tumor of the anterior mediastinum reveals the
inhomogeneous anterior mediastinal mass in contrast to the homoge-
neous density of a seminoma. Pleural effusion is also demonstrated in
the right hemithorax. (Reproduced with permission from Shields TW.
Primary lesions of the mediastinum and their investigation and treat-
ment. In: Shields TW, ed. General Thoracic Surgery. Baltimore:
Williams & Wilkins; 1994:1724–1769.)
chest pain, dyspnea, and fevers. Radiographic films may show
pneumomediastinum or pneumothoraces. If an esophageal per-
foration is suspected, an esophagogram should be performed.
Treatment is broad-spectrum antibiotics and surgical drainage
via a cervical incision and/or thoracotomy. Quick débridement
and drainage are key to patient survival. Minimally invasive
approaches to the chest may be adequate, but surgeons should
have a low threshold to perform a posterolateral thoracotomy,
which may give the best exposure and opportunity to débride
the chest. Sternal infections after cardiac surgery can also be a
serious problem requiring drainage and débridement. Ultimate
repair of the defect following débridement may involve muscle
or omental flaps for sternal reconstruction.
Chronic mediastinitis is a separate entity from acute medi-
astinitis and may arise from infectious sources or autoimmune
FIGURE 80.39. Computed tomography scan reveals a bronchogenic
cyst located in the subcranial area with compression of the left main-
stem bronchus with hyperinflation of the left lung and a mediastinal
shift to the right. (Reproduced with permission from Shields TW. Pri-
mary lesions of the mediastinum and their investigation and treat-
ment. In: Shields TW, ed. General Thoracic Surgery. Baltimore:
Williams & Wilkins; 1994:1764–1769).
1423
disorders. Patients may be asymptomatic until a mass effect is
seen on their mediastinal organs. CT scans are the best imag-
ing modality to diagnose this condition, and surgery is
reserved only for diagnosis or in the end stages of the disease
to relieve compression on other organs. Sclerosing mediastini-
tis may be seen in patients with retroperitoneal fibrosis.81
Superior Vena Cava (SVC) Syndrome
Superior vena cava syndrome is a rare condition seen when a
mediastinal mass compresses the SVC, resulting in facial and
upper body edema. Only 15,000 cases per year are seen in the
United States. Patients may present with cough, dyspnea, or
even stridor from upper airway edema. When patients start to
have symptoms, collateral venous drainage develops to drain
into the azygos vein or inferior vena cava. This process usually
takes weeks. Malignant tumors are the most common cause,
but venous thrombosis and nonmalignant lesions cause up to
one third of cases. CT scans are the best diagnostic test. Treat-
ment is based on supportive care and addressing the underly-
ing condition causing the obstruction. If a malignant tumor is
causing the obstruction, chemotherapy or radiotherapy may
shrink the tumor and lessen symptoms. Surgical resection with
SVC reconstruction may be used in specific tumors such as
locally advanced thymomas. Angioplasty and stenting may be
of benefit but is usually palliative.82 Although it is often felt to
be an emergency, most cases of SVC syndrome have a slowly
progressive course. When a patient develops symptoms, sup-
portive care, including possible intubation, will allow time for
LUNG
collateral venous drainage to develop and symptoms to
improve without other interventions. Although the median
survival is typically 6 months or less in patients with SVC syn-
drome from malignant obstruction, some have seen long-term
survivors when the primary tumors have responded to appro-
priate treatment.83 When patients present with severe symp-
toms, it is a mistake to rush to surgical intervention without a
long-term plan. Symptoms should be managed and the etiol-
ogy discovered and treated appropriately.
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