Pediatric emergency medicine trisk 4097 4097
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with low morbidity and mortality; thoracoscopic resection is feasible for some
lesions, with the remainder approached via traditional thoracotomy.
Bronchogenic Cyst
Bronchogenic cysts are believed to result from aberrant budding from the
primitive foregut or tracheobronchial tree. They arise from the trachea or a
bronchus and may be found anywhere along the tracheobroncheal tree, in the lung
substance, adjacent to the esophagus or in other ectopic locations.
Clinical Recognition
Centrally located cysts may present with symptoms caused by compression of an
airway or the esophagus. Wheezing, persistent cough, fever, recurrent pneumonia,
and dysphagia may result in such children. In infants and smaller children, large
airway compression can lead to significant and life-threatening air trapping and
CLE. In contrast, patients with peripherally located cysts are more likely to be
asymptomatic or present with milder, nonspecific symptoms, such as cough,
dyspnea, tachypnea, or wheezing. Physical examination is often unrevealing, but
in patients with large, centrally located lesions, tracheal deviation may be present.
Management
Initial detection of bronchogenic cysts almost always occurs by radiograph. Chest
radiograph may demonstrate findings of a smooth paratracheal or hilar mass,
airway displacement and/or air trapping, or a structure containing an air–fluid
level if there is communication with the airway or gastrointestinal tract (Fig.
124.8 ). CT scan and MRI are helpful in identifying and delineating the anatomic
relations of these lesions to surrounding structures. Cysts with turbid, mucoid
fluid may appear solid on CT scan.
The standard treatment of bronchogenic cysts is surgical resection, even if
asymptomatic. Active infection, if present, should be brought under control
before resection. Typically, this is done in the inpatient setting with intravenous
antibiotics and close observation. Asymptomatic cysts should be removed to
establish the diagnosis and to prevent the complications of secondary bronchial
communication, bleeding, or perforation into the pleural cavity. Carcinomas and
fibrosarcomas have been reported to arise in benign-appearing bronchogenic
cysts. Preservation of adjacent normal lung parenchyma is ideal, but some lesions
require concomitant wedge, segmental, or lobar lung resection. Thoracoscopy
may be used for some lesions, depending on their location and size.
