A rare cause of dysphagia and simultaneous hoarseness of voice in the octogenarian: a Killian-Jamieson diverticulum, management, and review of literature.

An 82-year-old male presented with progressive dysphagia and simultaneous hoarseness of voice for the past 6 months. He had mitral valve repair and a permanent pacemaker for a heart block 5 years ago. A computed tomographic scan of the neck demonstrated a cervical esophageal diverticulum. Oral Gastrogrifin contrast study confirmed esophageal diverticulum in Killian-Jamieson space. Open surgical diverticulectomy was performed safely. Patient's dysphagia resolved immediately, and he regained his normal voice after 6 weeks. Introduction: Killian-Jamieson's esophageal diverticulum is a rare form of pulsion diverticulum which originate through a muscular gap in the anterolateral wall of the esophagus, inferior to the cricopharyngeus muscle and superior to the circular and longitudinal muscle of the esophagus. Killian-Jamieson defined this area where the recurrent laryngeal nerve enters the pharynx, called Killian-Jamieson triangle. Ekberg and Nylander, in 1983, described an esophageal diverticulum in Killian-Jamieson space. The most common clinical manifestations in such patients are dysphagia, cough, epigastric pain, recurrent respiratory tract infections, and rarely hoarseness of voice. In symptomatic patients, surgical or endoscopic resection of the diverticulum is mandatory. We report this case in line with SCARE (Surgical CAse REport) criteria. Case Report: An 82-year-old male presented to our outpatient clinic with a history of progressive dysphagia for solid food and hoarseness of voice for the last 6 months. He denied gastroesophageal reflux, cough, and shortness of breath. On examination of the neck, there was swelling on the left side but no tenderness or lymphadenopathy. Basic blood investigations, including complete blood count, liver, and renal panels, were normal. An echocardiogram showed mild impairment of left ventricle function and normally functioning mitral valve. Chest X-ray showed a pacemaker in position. Computed tomography scan of the neck showed esophageal diverticulum. Gastrogrifin contrast study showed esophageal Killian-Jamieson diverticulum (KJD). Discussion: The acquired esophageal diverticulum is categorized into three types based on its anatomical location. Zenker's and Killian-Jamieson (pulsion diverticulum) in the proximal part, traction diverticulum in the middle part, due to pulling from fibrous adhesions following the lymph node infection and epiphanic pulsion type in the distal esophagus. Although the KJD and Zenker's diverticulum (ZD) arise close to each other in the pharyngoesophageal area, they are anatomically distinct. Although ZD and KJD have the same demographic features, they are more commonly found in older men (60-80 years) and women, respectively. The incidence of ZD is 0.01-0.11%, and KJD is 0.025% of the population. Rubesin et al. reported radiographic findings in 16 KJD cases. They found the majority of them were on the left side (72%), followed by 20% on the right side and 8% bilateral. Conclusion: In conclusion, we report a rare case of dysphagia and simultaneous hoarseness of voice in an octogenarian due to KJD, who was treated with open diverticulectomy, and dysphagia resolved; he regained his voice back after 6 weeks. In our opinion, endoscopic surgery in such a patient with KJD can put recurrent laryngeal at risk of injury since an endoscopic approach operator cannot visualize and dissect away the recurrent laryngeal nerve, particularly when KJD already compresses it.

A sudden hemorrhage in the esophageal duplication cyst: A rare cause of acute dysphagia in an adult.

A 42-year-old male pediatrics physician was admitted with a history of acute chest pain and sudden severe dysphagia to solids and liquids. He denied any history of abdominal pain, vomiting, dyspnea, nausea weight loss. He could not even swallow saliva. The patient denied any history of drug abuse. A computed tomographic scan of the chest (CT)showed a posterior mediastinal mass inseparable from the esophagus and descending aorta. Magnetic resonant imaging (MRI)scan revealed a cystic mass full of blood inseparable from the esophagus and adherent to the aorta. The mass was resected entirely through the left thoracotomy; post-operative recovery was uneventful; dysphagia resolved as the post-operative contrast swallow study showed a free flow of contrast to the stomach patient resumed his regular diet.

Dysphagia in a patient with Plumer Vinson syndrome: An innovative surgical dilatation technique after failed endoscopy.

For the last five years, a 43-year-old female presented with progressive dysphagia for solids and liquids. She was treated for iron deficiency anemia by systemic and oral iron therapy. Gastroenterologists failed to pass endoscopes through the upper esophagus. Gastrogrifin swallow revealed a critical narrowing of the esophagus. She was referred to a thoracic surgeon for further management. The cervical esophagus was exposed through the neck incision along the anterior border of the left sternocleidomastoid muscle, and esophageal dilatation was achieved using the silicon foleys catheter. It is a very safe and valuable surgical technique when dysphagia cannot be managed by endoscopically.

Two-stage surgery for delayed esophageal perforation and concomitant chylothorax secondary to upper gastrointestinal endoscopy.

A 46 years old male smoker was admitted to our hospital with a three-month history of chest discomfort and burning sensations due to regurgitation of food. The gastroenterologist tried multiple attempts to pass the endoscope through the lower end of the esophagus but failed. Post endoscopy Chest -X-ray showed right hemithorax fluid collection. A 28Fr chest drain was inserted, and fluid analysis revealed chyle. A contrast computed tomographic scan of the chest (CT) revealed esophageal perforation. The patient was managed conservatively by the primary physician on TPN, Antibiotics, and keeping him nil by mouth. After two weeks of failed conservative management, they referred the patient to the thoracic surgeon. We planned two-stage surgery because the patient was critically sick, septic, and hemodynamically unstable on inotropic support.

Cardiac arrest secondary to subclavian artery injury in blunt chest trauma: A lifesaving emergency surgery in COVID crises.

A 25-year-old male vehicle driver had a road traffic accident and sustained a blunt chest injury. His chest x-ray in the emergency department showed left hemithorax opacification. A chest drain Fr32 was inserted, and 1300ml of Blood drained out. While having a computed tomographic scan of the thorax scan, he had a cardiac arrest and after Cardiopulmonary Resuscitation (CPR) he was transferred to our tertiary care hospital on a mechanical ventilator and massive ionotropic support (adrenaline and noradrenaline) with a blood pressure of 50/24 mmHg. We performed a lifesaving emergency thoracotomy in a supine position with all COVID precautions, as COVID status was not available before hospitalization. After the repair of the Subclavian artery patient recovered completely and was discharged for follow-up in outpatient.

Radical surgical resection of giant Angiosarcoma of the posterior Mediastinum: A rare neoplasm with rare presentation as epigastric pain.

Angiosarcoma of the Posterior Mediastinum is a rare entity. We herein report a case of a giant posterior mediastinal Angiosarcoma. A 54-year female presented with a one-year history of epigastric pain. Her upper gastrointestinal tract endoscopy revealed no abnormality. Chest x-Ray showed a shadow in the hilar area. A computed tomographic scan of the Thorax (CT) and MRI Scan showed a mass in the Posterior Mediastinum. CT-guided biopsy revealed the tumor of vascular origin. The tumor was completely resected. Post-operative recovery was uneventful. After 14 months follow up patient is disease-free, and a CT scan of the chest showed no recurrence.

The diagnostic and prognostic value of tumor markers in giant mediastinal endodermal sinus tumor with prolonged survival: Twelve-year follow up after radical resection.

We report a case of 16 -year male who presented with nonproductive cough, chest pain, and hemoptysis. His chest -x-ray and computerized tomographic scan (CT) of the thorax with contrast enhancement revealed a large mediastinal mass mostly occupying the left hemithorax. Percutaneous CT scan-guided biopsy of the mediastinal mass was reported as an endodermal sinus tumor (EDST). Serum alpha-fetoprotein levels were markedly raised (120,000 ng/ml). After completion of chemotherapy repeat, CT scan of the thorax revealed a large residual mass. Radical resection of the tumor was carried out. Twelve-year post-surgical resection follow-up with serial serum alpha-fetoprotein (AFP) tumor marker levels and CT scan of the thorax showed no recurrence.

Bronchopleural fistula in a 5- years old child with novel CARMIL 2 mutation: A rare disease and a rare case.

A five year girl had eczema and allergic rhinitis in the past, presented with a history of cough, shortness of breath for the last one month. Her chest -X-ray showed a left side pleural effusion, and a computed tomographic scan (CT) of the chest showed left side hydropneumothorax. Left side 21 Fr drain was inserted. Her clinical condition deteriorated despite antimicrobial therapy, and she required mechanical ventilatory support due to respiratory distress. She also developed a right-sided pneumothorax that was managed by inserting a 21 Fr chest drain. A video-assisted thoracoscopic VATS procedure was done to staple the lung bullae and drain the empyema. Her post-operative chest X-ray showed good lung expansion. Pleural fluid culture report was positive for candida. She was commenced on antifungal microbial therapy. Two days later, she developed again left side pneumothorax, which was again managed by left intercostal drain. We were unable to wean her off from mechanical ventilatory support due to a significant air leak due to bronchopleural fistula. A posterolateral thoracotomy was performed, and the bronchopleural fistula was closed. She was extubated the next day, and intercostal drains were removed on the 4th post-operative day.

Modified surgical reconstruction technique for a rare isolated congenital sternal cleft: In a six -year-old child.

We report the modified surgical reconstruction technique for correction for a large isolated congenital sternal cleft in 6 years old girl using a methyl methacrylate marlex mesh sandwich plate (MMS). The patient was referred to our tertiary care institution with a sizeable anterior chest wall bony defect. There was a large bulging under the skin due to protrusion of mediastinal viscera and visible cardiac pulsations with breathing. A chest x-ray and computed tomographic scan (CT) of the thorax was done to evaluate the bony defect. We reconstructed the sternal bony defect by our innovative technique using methyl methacrylate. The patient was discharged after three days for further follow up in outpatient. One year follow up patient is doing well with excellent results. Our technique is simple, cost-effective, and provides a perfect cosmetic effect for children's sternal large defects. INTRODUCTION: Sternal clefts are rare congenital malformations that result from the defective embryologic fusion of paired mesodermal bands in the midline. This rare anomaly incidence is 1:100,000 cases per live births, which constitute 1% of all congenital chest wall deformities. The first Case of the sternal cleft was reported in 1740. The hereditary sternal gap is rare, and hence sporadic cases have been reported in the medical literature. Ravitch described that the first surgical correction was reported by Lannelongue et al., in 1988., But Burton published the first successful repair in 19474. An isolated sternal cleft is a rare entity and is classified into two categories' complete and incomplete sternal gap. Early repair is recommended; otherwise, surgical correction is challenging in children as the hypo plastic sternal edges cannot be approximated primarily, and this requires prosthetic, autologous grafts or some kind of parasternal chondroplasties. CASE PRESENTATION: Since birth, a six-year-old girl was referred to our tertiary care center with a large central chest wall defect. She was a full-term normal delivery with no other congenital malformations. The defect was noticed at birth and became more evident as she grew up. In addition to cosmetic concern on coughing, there was bulging under the skin and visible cardiac pulsation. On examination, there was a large gap (7cm) in the midline of the chest with sternal adages well apart, moving independently. DISCUSSION: The sternal cleft is a congenital anomaly with less than 0.15% and is more common in the female gender. Isolated sternal cleft without any other associated abnormalities is very rare. It has been reported as a part of defined syndromes like PENTALOGY OF CANTRELL, VACTREL, DANDY WALKER, and PHASE (Posterior fossa brain malformation, hemangioma, arterial lesions, cardiac abnormalities, and eye abnormality).6 Embryo logically sternum originate from the somatic layer of lateral mesodermal plates as bilateral bands. They fuse in the midline by the 10th week to constitute a cartilaginous framework of manubrium, sternum, and xiphoid process. Failure of this fusion can lead to a partial or complete sternal cleft.7 Etiology of this disease is unknown; however, it has been linked with riboflavin or methyl-cobalamin deficiency, high alcohol intake during pregnancy. CONCLUSION: in conclusion, our improvised reconstruction technique for large sternal cleft in children has several advantages. There is no need to do extensive chordotomies or using bone grafts. Less complicated procedure Provides more rigid frame for protection of thoracic structures and better chest wall stability. Hospital stay is minimal and is very cost-effective. The child's future growth is not affected as ribs and costal cartilages are left intact in this technique. There is no chance of displacement or excursion of the MMS plate. In female patients, this provides better cosmoses as there is no need to mobilize the pectoralis significant muscles flaps for coverage. The geometry of the rib cage is well preserved.

A rare cause of right ventricle out flow tract obstruction: Anterior mediastinal teratoma.

A 36 years old female presented with six months history of shortness of breath, fatigue, and tiredness. Her chest X-Ray showed a left mediastinal mass. A computed tomographic scan (CT)of the chest revealed a left mediastinal mass, exhibiting typical teratoma features. An echocardiogram showed compression of the main pulmonary artery causing right ventricular out flow tract obstruction. The tumor was resected through a left thoracotomy, and the patient improved dramatically after surgery. She was discharged home for further follow-up.

Radical resection and improvised manubriosternal reconstruction technique for solitary manubriosternal metastasis from papillary thyroid cancer.

INTRODUCTION: Thyroid papillary carcinoma rarely present as manubriosternum metastasis. The standard treatment for patients with metastatic disease is iodine ablation therapy. A surgical resection is a good option for patients with resectable limited bony metastasis. CASE PRESENTATION: We report a case of a 50-year-old female with thyroid gland enlargement. Positron emission tomography scan (PET) showed a solitary manubriosternal metastasis. The patient underwent total thyroidectomy and claviculo-manubriosternal en-bloc resection and improvised reconstruction using Methyl methacrylate marlex mesh plate (MMS). Post-operative recovery was uneventful, and the patient received adjuvant radioactive iodine (RAI) treatment. At five year follow up patient remained disease-free. CONCLUSION: In conclusion, we report a case of papillary carcinoma of thyroid with solitary manubriosternal metastasis treated with total thyroidectomy and radical en-bloc resection of clavicular heads, manubriosternal and reconstruction by our modified reconstruction technique, which provides the best MMS plate stability, cosmoses, and good disease-free survival. In solitary bony metastasis for thyroid cancer, radical resection followed by a RAI ablation, is the best treatment modality.

Innovative surgical technique for removal of Light Emitting Diode from segmental bronchus in a child: After the failure of endoscopic retrieval.

A five years boy aspirated Light-emitting diode (LED) of a toy while playing. Initially, he had a cough which later on settled. Chest physician at the local hospital tried to retrieve foreign bodies endoscopically, but he failed. He was referred to our tertiary care hospital. Chest physician and pediatric ear, nose and throat surgeon (ENT) were unable to remove it endoscopically as the (LED) migrated further into posterior basal segmental bronchus with manipulation. We removed this foreign body with our innovative lung parachymal sparing surgical technique without compromising the airway integrity. Post-operative follow up showed full lung expansion. The child was discharged home safely and follow up chest X-ray was unremarkable.

Mediastinal malignant triton tumor: A rare case series and review of literature.

INTRODUCTION: In 1938, the Malignant Triton Tumor (MTT) was first explained by Mason. CASE PRESENTATION: Case 1: A man aged 28 years presented with chest pain and difficulty in breathing since last five months, there was no history of cough fever or night sweats. Clinical examination was unremarkable. His routine hematological tests including tumor markers were within normal range, testicular ultrasound was normal. CT scan of thorax revealed a mass in the anterior mediastinum. CT guided biopsy revealed a malignant triton tumor. Case 2: A 30 years old man, nonsmoker presented with history of chest tightness and feeling pressure while kneeling down since last 3 months, otherwise fit and healthy. His routine hematological investigations including tumor markers were within normal range. A CT scan of thorax revealed a large mass in the right posterior mediastinum. CT guided biopsy showed malignant triton tumor. Case 3: A man aged 28 years presented with chest pain and difficulty in breathing since last five months, there was no history of cough fever or night sweats. Clinical examination was unremarkable. His routine hematological tests including tumor markers were within normal range, testicular ultrasound was normal. CT scan of thorax revealed a mass in the anterior mediastinum. CT guided biopsy revealed a malignant triton tumor. DISCUSSION: Malignant peripheral nerve sheath tumors (MPNST) are uncommon sarcomatous tumors that are believed to be derived from Schwann cell or neighboring cells with perineurial differentiation. MTT is rarely reported in mediastinum, lung and heart (<10%) To the best of our knowledge, only few cases of MTT in the mediastinum have been reported in English literature, including, four were reported in the anterior mediastinum, three in the posterior mediastinum, one in the middle mediastinum and one between the ascending aorta and the main pulmonary artery. Most of the patients were young adults. We report three cases of rare mediastinal malignant triton tumors. They have been treated with palliative surgery/radical surgery +/- adjuvant therapy. The prognosis varied from a 3 month overall survival time to being alive at a 53 month follow-up period. CONCLUSION: In conclusion we report three rare cases of mediastinal malignant triton tumor treated with radical surgical resection and post-operative radiotherapy, one patient developed lung metastasis, and two had late local recurrence. The malignant triton tumor is a lethal neoplasm which carries very poor prognosis particularly when they occur in the mediastinum because it's very difficult to obtain wider tumor free margin due to the nature of location site.

Radical chest wall resection and modified reconstruction technique for solitary internal mammary lymph node recurrence in breast cancer.

INTRODUCTION: Although the incidence of internal mammary lymph node recurrence rate in breast cancer is low but still it is the second most common drainage site after axilla. Patients with solitary internal mammary lymph node (IMLN) recurrence have overall better prognosis. The role of chemo and radiotherapy in internal mammary lymph node involvement with breast cancer is still controversial. Radical surgical resection and reconstruction remains mainstay for good prognosis. PRESENTATION OF CASE: Here in we present a case of a 32 year old female with breast cancer who had left mastectomy followed by adjuvant chemo radiotherapy treatment for adenocarcinoma of breast in 2008. She presented with upper left parasternal pain in 2009. Computed tomographic scan (CT) of her thorax showed internal mammary lymph node enlargement, likely metastasis. We performed modified surgical reconstruction after enbloc radical resection of part of manubrium; hemi sternum, chest wall and left parasternal IMLN. Patient remained disease free to date. DISCUSSION: There is no standard treatment after IMLN metastasis. Previous surgical studies reported no survival benefit with ERM, but is there any role of adjuvant locoregional radiotherapy or systemic therapy to prevent relapses in IMLN is a matter of debate. CONCLUSION: To the best of our knowledge this is first case ever managed with radical enbloc surgical resection and modified reconstruction of chest wall using such technique. Our reconstruction technique provides better chest wall stability with minimal risk of plate dislodgement or excursion and at the same time provides good cosmoses and better survival.

Radical resection and improvised surgical reconstruction for a rare malignant triton tumour of intercostal nerve in a patient with neurofibromatosis type 1.

A man aged 28 years, with neurofibromatosis type 1, presented with abdominal pain and visible right lower chest swelling. He had cutaneous neurofibromas and several café-au-lait spots. CT scan of the chest and abdomen revealed a giant mass most likely originating from the right 7th intercostal nerve, extending downwards into the abdomen causing massive hepatic compression. A Trucut biopsy showed malignant peripheral nerve sheath tumour. Radical surgical resection with wide margins was performed. The chest wall and diaphragm were reconstructed with improvised surgical technique with excellent results. Final histopathology report revealed a triton tumour of the intercostal nerve.

Hoarseness of voice, respiratory distress and dysphagia due to giant primary posterior mediastinal ectopic goitre: a rare clinical entity.

Primary posterior mediastinal ectopic goitre is an extremely rare entity; we report a case of a 28-year-old man who presented with dysphagia, respiratory distress and hoarseness of voice, gradually worsening over a period of 3 months. CT scan of the thorax revealed a giant posterior mediastinal ectopic goitre. The mass was removed through a right posterolateral thoracotomy. The patient's symptoms, respiratory distress and dysphagia disappeared immediately after surgery while his voice gradually returned to normal after 6 weeks.

Late Intrathoracic Tracheal Stricture After Blunt Chest Trauma: A Rare Life-Threatening Condition.

Tracheal injury after blunt chest trauma is a rare but life-threatening condition. If diagnosed and treated early, the outcome is excellent. We report a case of an 18-year-old man who sustained a fracture of the right femur in a traffic accident. He underwent operation under spinal anesthesia and was discharged home after 2 weeks. Six weeks later, he was readmitted with acute respiratory distress, stridor, and drowsiness. Arterial blood gas analysis showed hypercarbia (PCO2 of 80 mm Hg; PO2 of 60 mm Hg). He was intubated with difficulty and ventilated. A computed tomographic (CT) scan of the chest showed a very tight supracarinal tracheal stricture. Emergency surgical resection of the tracheal stricture was performed, and an end-to-end anastomosis was fashioned. The patient had an excellent recovery.

Manubrioclavicular and Manubriosternal Reconstruction After Radical Resection for Chondrosarcoma of Manubriosternum: A Modified Surgical Technique.

Primary chondrosarcoma of the manubriosternum is a rare tumor. We describe the case of a 42 year-old man who presented with a swelling of the anterior chest wall. The computed tomography scan of the thorax showed a manubriosternal mass involving both clavicles. True-cut biopsy revealed a low-grade chondrosarcoma. The manubrium, the medial part of the clavicles, the sternum, and all costal cartilages were excised en bloc with wide, clear margins and reconstructed successfully without any residual deficit regarding the stability of the chest wall and upper arm movements. We present this rare case with a modified reconstruction technique using a methyl methacrylate Marlex mesh sandwich plate with excellent results. After 2 years' follow-up, there was no radiologic or clinical signs of recurrence.

Radical surgical resection for giant primary mediastinal endodermal sinus tumour with pulmonary metastasis after chemotherapy: can be curative.

Primary non-seminomatous germ cell tumours of anterior mediastinum are uncommon. Endodermal sinus tumour of the anterior mediastinum (yolk sac) is a rare but lethal neoplasm. We present a case of an 18-year-old man who presented with chest pain, cough and haemosputum with markedly raised serum α-fetoprotein (AFP) levels above 112,000 ng/mL. Chest roentgenogram and CT showed a giant anterior mediastinal mass. CT guided biopsy revealed a diagnosis of endodermal sinus tumour. After the completion of chemotherapy, extensive surgical resection was carried out along with the right lung metastastectomy. Five years postresection follow-up the patient is disease free with normal serum tumour markers. This is the longest survival ever reported of such tumours with highest AFP level (>112,000 ng/mL) and lung metastasis.

A rare cause of asymptomatic solitary pulmonary nodule: adult Schistosoma worm.

Solitary pulmonary nodule due to various pathologies has been reported in the medical literature. We report a case of solitary pulmonary nodule in an asymptomatic 60-year-old male smoker, who had a positive family history of pulmonary tuberculosis. His routine screening chest X-ray revealed a 2 × 1.5 cm nodule in the right lung upper zone. A CT scan of the thorax confirmed the finding. Bronchoscopy, lavage, biopsy and screening for tuberculosis were negative. Owing to its technical difficulty, a CT-guided biopsy was deferred by the radiologist, hence we decided to perform segmentectomy that showed granuloma harbouring an adult Schistosoma worm. This is the first case of asymptomatic solitary pulmonary nodule due to adult Schistosoma worm 26 years after the exposure.