SESSION TITLE: Great Procedural Cases: Fire, Ice, Struts, Valves, and GlueSESSION TYPE: Case ReportsPRESENTED ON: 10/19/2022 11:15 am - 12:15 pmINTRODUCTION: Flexible bronchoscopy and EBUS-TBNA is an effective tool for cancer staging and diagnosing mediastinal lymphadenopathy. It is a commonly performed procedure and overall safe for patients with minimal complications. The following case highlights a rare but important complication of EBUS-TBNA.CASE PRESENTATION: A 63 YO F with PMH of 20 pack year tobacco use presented for evaluation of a 2.6cm x 2.4cm RUL nodule and mediastinal lymphadenopathy. She underwent navigational bronchoscopy of RUL nodule and EBUS-TBNA for mediastinal staging. EBUS-TBNA was performed using an Olympus 21G needle at stations 11L, 4L, 7, 4R and 11R. She recovered post-procedure and discharged home. The following evening, she developed shortness of breath and "wheezing” which prompted her to report to ER. On exam, she had audible inspiratory and expiratory stridor and lungs were clear to auscultation BL. CXR showed a small right apical pneumothorax which resolved with conservative management. However, her stridor and shortness of breath was unchanged. Thus, repeat flexible bronchoscopy was performed demonstrating interval development of granulation tissue in the lower trachea and in the right main bronchus with complete obstruction of the right main bronchus. The granulation tissue formed at the TBNA puncture site at stations 7 and 4R. Ultimately, the granulation tissue was excised using cryotherapy and she was given oral corticosteroids to prevent further development of granulation tissue.DISCUSSION: The development of granulation tissue or granulomatous inflammation at the puncture biopsy site is a rare complication of TBNA. Our literature search returned six cases that describes the development of granulation tissue or granulomatous inflammation following TBNA. Of the six cases reported, this complication was identified between two weeks to six months. About one-third of these patients developed symptoms including cough and shortness of breath, whereas the others were incidentally found on repeat bronchoscopy or follow-up CT scan. In patients with malignancy, there was concern for metastasis to the puncture site leading to repeat flexible bronchoscopy and biopsy. In most of the reported cases, the granulation tissue and granulomatous inflammation resolved with conservative treatment alone. However, those who develop central airway obstruction warrant further bronchoscopic intervention.CONCLUSIONS: Granulation formation and granulomatous inflammation after TBNA is uncommon and often resolve without intervention, however, it could result in significant airway obstruction. We urge clinician awareness of this exceedingly rare phenomenon as airway occlusion may be life threatening and should be considered promptly.Reference #1: Madan K, Tiwari P, Arava S, Hadda V, Mohan A, Guleria R. Tracheobronchial puncture-site nodular reaction (TPNR) following endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): Systematic review of case reports. Lung India. 2017 Nov-Dec;34(6):532-537. doi: 10.4103/lungindia.lungindia_12_17. PMID: 29098999; PMCID: PMC5684811.Reference #2: Lee JW, Kim WJ, Park CW, Kang HW, Ban HJ, Oh IJ, Kwon YS, Kim KS, Kim YI, Lim SC, Kim YC, Choi YD. Endotracheal tuberculous granuloma formation following endobronchial ultrasound transbronchial needle aspiration. Intern Med. 2013;52(11):1207-10. doi: 10.2169/internalmedicine.52.9360. PMID: 23728557.Reference #3: Asano F, Aoe M, Ohsaki Y, et al. Complications associated with endobronchial ultrasound-guided transbronchial needle aspiration: a nationwide survey by the Japan Society for Respiratory Endoscopy. Respir Res. 2013;14(1):50. Published 2013 May 10. doi:10.1186/1465-9921-14-50DISCLOSURES: No relevant relationships by Hitesh BatraNo relevant relationships by Anneka HuttonNo relevant relationships by Melissa Jordan SESSION TITLE: Great Procedural Cases: Fire, Ice, Struts, Valves, and Glue SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: Flexible bronchoscopy and EBUS-TBNA is an effective tool for cancer staging and diagnosing mediastinal lymphadenopathy. It is a commonly performed procedure and overall safe for patients with minimal complications. The following case highlights a rare but important complication of EBUS-TBNA. CASE PRESENTATION: A 63 YO F with PMH of 20 pack year tobacco use presented for evaluation of a 2.6cm x 2.4cm RUL nodule and mediastinal lymphadenopathy. She underwent navigational bronchoscopy of RUL nodule and EBUS-TBNA for mediastinal staging. EBUS-TBNA was performed using an Olympus 21G needle at stations 11L, 4L, 7, 4R and 11R. She recovered post-procedure and discharged home. The following evening, she developed shortness of breath and "wheezing” which prompted her to report to ER. On exam, she had audible inspiratory and expiratory stridor and lungs were clear to auscultation BL. CXR showed a small right apical pneumothorax which resolved with conservative management. However, her stridor and shortness of breath was unchanged. Thus, repeat flexible bronchoscopy was performed demonstrating interval development of granulation tissue in the lower trachea and in the right main bronchus with complete obstruction of the right main bronchus. The granulation tissue formed at the TBNA puncture site at stations 7 and 4R. Ultimately, the granulation tissue was excised using cryotherapy and she was given oral corticosteroids to prevent further development of granulation tissue. DISCUSSION: The development of granulation tissue or granulomatous inflammation at the puncture biopsy site is a rare complication of TBNA. Our literature search returned six cases that describes the development of granulation tissue or granulomatous inflammation following TBNA. Of the six cases reported, this complication was identified between two weeks to six months. About one-third of these patients developed symptoms including cough and shortness of breath, whereas the others were incidentally found on repeat bronchoscopy or follow-up CT scan. In patients with malignancy, there was concern for metastasis to the puncture site leading to repeat flexible bronchoscopy and biopsy. In most of the reported cases, the granulation tissue and granulomatous inflammation resolved with conservative treatment alone. However, those who develop central airway obstruction warrant further bronchoscopic intervention. CONCLUSIONS: Granulation formation and granulomatous inflammation after TBNA is uncommon and often resolve without intervention, however, it could result in significant airway obstruction. We urge clinician awareness of this exceedingly rare phenomenon as airway occlusion may be life threatening and should be considered promptly. Reference #1: Madan K, Tiwari P, Arava S, Hadda V, Mohan A, Guleria R. Tracheobronchial puncture-site nodular reaction (TPNR) following endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): Systematic review of case reports. Lung India. 2017 Nov-Dec;34(6):532-537. doi: 10.4103/lungindia.lungindia_12_17. PMID: 29098999; PMCID: PMC5684811. Reference #2: Lee JW, Kim WJ, Park CW, Kang HW, Ban HJ, Oh IJ, Kwon YS, Kim KS, Kim YI, Lim SC, Kim YC, Choi YD. Endotracheal tuberculous granuloma formation following endobronchial ultrasound transbronchial needle aspiration. Intern Med. 2013;52(11):1207-10. doi: 10.2169/internalmedicine.52.9360. PMID: 23728557. Reference #3: Asano F, Aoe M, Ohsaki Y, et al. Complications associated with endobronchial ultrasound-guided transbronchial needle aspiration: a nationwide survey by the Japan Society for Respiratory Endoscopy. Respir Res. 2013;14(1):50. Published 2013 May 10. doi:10.1186/1465-9921-14-50 DISCLOSURES: No relevant relationships by Hitesh Batra No relevant relationships by Anneka Hutton No relevant relationships by Melissa Jordan