The diagnostic and therapeutic use of bronchoscopy in fibrosing mediastinitis

Purpose: While bronchoscopy may be employed diagnostically in suspected fibrosing mediastinitis, few descriptions of its use exist in the literature. We describe the bronchoscopic findings of fibrosing mediastinitis; in addition, therapeutic use of bronchoscopy is presented. Methods: We reviewed charts of all patients with fibrosing mediastinitis, in whom bronchoscopy was performed, between 1976 and 1997. 35 patients met inclusion criteria, with 48 bronchoscopies performed in these patients. Data were collected from bronchoscopy reports, radiographic reports, pathology and- where available- thoracic surgical records. Results: The most common findings at bronchoscopy were: airway stenosis/ compression in 33 patients (97%); bronchitis in 8 patients (23%); mucosal abnormalities other than bronchitis in 30 patients (86%), including friability and hemorrhage in 18 patients (51%); and thickened carinas in 6 patients (17%). Normal exam was seen in one patient (3%). Bronchial biopsies yielded chronic inflammation, fibrosis and granulomatous features. The most frequent complication was hemorrhage, occurring in 12 bronchoscopies (25%) but requiring procedure termination in only two. Severe or massive hemorrhage occurred in only two cases, and no mortality was experienced. Balloon dilatation with or without endobronchial stenting was successful in 3 of 4 cases, with improved symptoms, PaO2 (average improvement 13mmHg) and FEV₁ (average improvement 23%). Hemorrhage control and granulation removal were also efficacious. Conclusions: Bronchoscopy is frequently abnormal in fibrosing mediastinitis, and frequently complicated by hemorrhage. Bronchoscopic intervention may improve symptoms of the disease. Clinical Implications: Bronchoscopic abnormalities, while not pathognomonic for fibrosing mediastinitis, may be of significant assistance in its diagnosis. While bronchoscopy proved to be relatively safe, the incidence of bleeding was high, and the operator should be prepared for significant hemorrhage in these patients. In select patients, transbronchoscopic therapeutic interventions may provide significant anatomic and symptomatic relief, with no severe complications observed.