CASE REPORTS Heart, Lung and Circulation Case Reports 515 2008;17:505–518 Chamberlain Mediastinotomy for Diagnosis of Adenoid Cystic Carcinoma of Trachea Saulat H. Fatimi, MD, FACS a , Rubina A. Sajwani, MBBS a , Nadeem Rizvi, MBBS b and Muhammad A. Javed, MD a Asmatullah Khan, MBBS a Usman Ahmad, MD a,∗ a Department of Surgery, Division of Cardiothoracic Surgery, Aga Khan University, Karachi, Pakistan b Division of Chest Diseases, Jinnah Post Graduate Medical Center, Karachi, Pakistan Primary tracheal tumours are extremely rare. Bronchoscopy is the standard diagnostic procedure of obtaining biopsy of a tracheal mass, however it becomes challenging if the obstructing lesion is placed distally along the trachea occluding greater than 90% of the airway. We report the case of a 25-year-old male who suffered from severe tracheal stenosis. The lesion was biopsied through a chamberlain mediastinotomy, under local and mask anaesthesia and was found to be primary adenoid cystic carcinoma. (Heart, Lung and Circulation 2008;17:505–518) © 2007 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Chamberlain’s mediastinotomy; Anterior mediastinotomy; Adenoid cystic carcinoma; Trachea Introduction P rimary tracheal malignancy has an incidence of <2 mil- lion persons per year. 1 Malignant lesions rarely cause tracheal stenosis, but when present, adenoid cystic carci- noma (ACC) is the second most common histologic type. 1,2 Rigid bronchoscopy under general anaesthesia (GA)is the conventionaltechnique employed to biopsy, 1–3 but management of airway in patients with severe tracheal obstruction is challenging for both the surgeon and the anaesthesiologist. 4 We report our successful experience of establishing diagnosis of primary tracheal ACC in a patient with severe tracheal stenosis using chamberlain’s mediastinotomy under local and mask anaesthesia. Case Presentation A 25-year-old nonsmoker male presented with progres- sively worsening dyspnoea for2 years and exertional dyspnoea for 5 months. He was initially treated for asthma at another hospital but his condition soon deteriorated and he developed severe breathlessness on lying supine. Chest roentgenogram and thoracic computed tomographic scan showed a homogenous circumtracheal mass extending from lower part of trachea to the carina obstructing greater Received 11 February 2007; received in revised form 21 July 2007; accepted 30 July 2007; available online 10 October 2007 ∗ Corresponding author at:Departmentof Surgery,Yale Uni- versity,Boyer Center for Molecular Medicine, Room 437,295 Congress Ave, New Haven, CT 06510, USA. Tel.: +1 203 737 2289. E-mail address: usman.ahmad@yale.edu (U. Ahmad). than 85% of the tracheal lumen. He was referred to our centre for an elective biopsy. The patient had no past history of tuberculosisor other medicalcomorbids including diabetes, hyperten- sion, asthma, gastro-oesophageal reflux or allergy. Chest examination revealed grade IV wheezing and expiratory stridor.Chest wall retractions were also observed. Arte- rial blood gases in room air showed mild hypoxaemia and CO 2 retention, with PaO 2 = 75 mmHg, PaCO 2 = 46 mmHg and oxygen saturation of 96%. Considering the patients’inability to lie supine and to undergo intubation,Chamberlain’s mediastinotomy was carried out under local and inhalation anaesthesia, with the patient in a semi-recumbent position. After infil- trating the area with 2% xylocaine and epinephrine, an incision was made above the third rib in the second inter- costalspace on the rightside. The superior vena cava, phrenic nerve,aorta and trachea were identified.The trachea was narrow and fibrotic. Multiple biopsy sam- ples of tissue around the trachea and carina along with several paratracheal lymph nodes were taken. Frozen sec- tion was performed to ensure thathe tissue obtained was a representative specimen. Histopathological exam- ination showed the biopsy specimen to be positive for epithelial carcinoma. Final histopathological examination confirmed infiltrating ACC (Fig. 1). Post-operatively, the patient required 3 days to recover and had to be observed for a day as he was retaining CO 2 . There were no major operative complications. Unfortu- nately further management was hindered as the patient failed to follow up. © 2007 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. 1443-9506/04/$30.00 doi:10.1016/j.hlc.2007.07.008