The real value of endobronchial ultrasound

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become a standard procedure worldwide, used in conjunction with bronchoscopy to obtain biopsies for mediastinal disorders. A 67-year-old man with a 40 pack-year smoking history presented with a 2-year history of hoarseness and weight loss. He also had a history of asbestos exposure. On examination under anaesthesia a lesion of the right false vocal fold was found and histology showed a moderately differentiated infiltrating keratinising squamous carcinoma. The question posed was whether this mass could be ascribed to metastatic supraglottic carcinoma or if it was indeed a metachronous primary bronchus carcinoma, as the treatment of these two malignancies differs significantly. Traditional bronchoscopy with TBNA is the least invasive procedure to obtain a cytological diagnosis, but the proximity of the aorta and pulmonary arteries and the mass being 14 mm from the bronchus would have made sampling by means of this procedure near impossible. We used EBUS to localise the mass and noted the position of the major vessels on Doppler ultrasound. Real-time ultrasound guidance allowed us to bridge the tissue plane between the mass and bronchial lumen using the longer EBUS needle and to obtain a fine-needle aspirate of the mass, which proved to be a keratinising squamous carcinoma. We describe this case in which EBUS-TBNA was pivotal in reducing the number of invasive procedures in a patient with metastatic supraglottic carcinoma.