Bilateral Hilar Lymphadenopathy Diagnosed with EBUS-Guided Needle Aspiration

The Problem

The patient was a 42-year-old woman with a three-month history of dry cough, mild breathlessness on exertion, and persistent fatigue. A routine chest X-ray showed enlargement of the lymph nodes at both lung hila, and she was referred to a pulmonologist in Noida for further evaluation.

A contrast CT of the chest confirmed bilateral hilar and mediastinal lymphadenopathy. Enlarged lymph nodes in this distribution have several possible causes, including sarcoidosis, tuberculosis, and lymphoma. These conditions require very different treatment, so a tissue diagnosis was essential before any therapy could begin.

The traditional route to these lymph nodes is mediastinoscopy, a surgical procedure performed under general anaesthesia through an incision at the base of the neck. It carries surgical risks, needs a hospital stay, and leaves a scar. The uncertainty of an unexplained abnormal scan, together with the prospect of chest surgery for a diagnosis, was a significant source of anxiety for the patient.

What Was Assessed

• Detailed clinical history covering the duration of cough, breathlessness, fatigue, fever, night sweats, and weight loss.
• Review of the chest X-ray and contrast CT to map the size, number, and stations of the enlarged lymph nodes.
• Blood investigations, including serum ACE and calcium, and screening for tuberculosis.
• Assessment of the differential diagnosis: sarcoidosis, tuberculosis, and lymphoma.
• Evaluation of fitness for a bronchoscopic procedure under moderate sedation.

Why This Approach Was Chosen

Dr. Manu Madan recommended EBUS-guided transbronchial needle aspiration (EBUS-TBNA) as the first-line diagnostic procedure, in preference to open mediastinoscopy, for clear reasons:

• Minimally invasive: the lymph nodes are reached through the airway using a bronchoscope fitted with an ultrasound probe, with no incision and no scar.
• Real-time accuracy: the ultrasound shows the needle entering the node as the sample is taken, allowing precise targeting of multiple nodal stations in one session.
• Safer profile: EBUS avoids general anaesthesia and the surgical risks of mediastinoscopy, and is completed as a day-care procedure.
• Comparable diagnostic yield: for bilateral hilar lymphadenopathy, EBUS-TBNA achieves a diagnostic accuracy comparable to surgical biopsy in most cases.

Procedure Facts

The aspirates showed non-caseating granulomas, and stains and cultures for tuberculosis were negative. Together with the clinical picture and blood results, this confirmed a diagnosis of sarcoidosis. A surgical biopsy was avoided entirely.

With a definitive diagnosis in hand, appropriate treatment was started without delay, and a monitoring plan was set for lung function and symptoms. The patient returned to her normal routine the day after the procedure.

Outcomes at a Glance

Recorded during clinical follow-up:

“I had been told I might need chest surgery just to find out what was wrong, which was a difficult prospect. Dr. Manu Madan explained that the same answer could be obtained through the airway with EBUS. The procedure was completed in under an hour, I went home the same day, and within a week I had a confirmed diagnosis and a treatment plan.”

Instructions Given to the Patient

• Avoid eating or drinking for two hours after the procedure until the sedation and throat numbness wear off.
• Expect a mild sore throat or a small amount of blood-streaked sputum for a day; report anything more than this.
• Avoid driving or operating machinery on the day of the procedure.
• Attend the review appointment for the biopsy results, usually available within three to seven days.
• Begin the prescribed treatment once the diagnosis is confirmed, and attend scheduled follow-up with lung function testing.

Recovery Timeline

This case was managed by Dr. Manu Madan, Senior Consultant in Respiratory and Sleep Medicine at Medanta Hospital, Noida