Tracheoceles Paratracheal air cysts True diverticula Herniation of the tracheal air column through a weakened posterior tracheal membrane Occur almost exclusively in the cervical trachea Usually asymptomatic CT: circular lucencies along the right posterolateral trachea at the thoracic inlet Tracheal bronchus Bronchus suis Consists of an accessory bronchus to all or a portion of the right upper lobe that arises from the right lateral tracheal wall within 2 cm of the tracheal carina Most often supplies the apical segment of the right upper lobe Asymptomatic Usually an incidental finding on chest CT Association with congenital tracheal stenosis and an aberrant left PA Focal Tracheal Disease Extrinsic Mass Effect Most common cause: tortuous or dilated aortic arch or brachiocephalic artery Because the tracheal cartilage provides resiliency, extrinsic masses tend to displace the trachea without narrowing its lumen Traction deformity of the trachea is generally seen in cicatrizing processes that asymmetrically affect the lung apices (i.e., postprimary tuberculosis (TB), histoplasmosis, and radiation fibrosis) Focal Tracheal Stenosis May result from inflammatory disorders that affect the tracheal or central bronchial walls From cartilaginous damage or the development of granulation tissue and fibrosis from a tracheostomy or at the site of a previously inflated endotracheal tube balloon cuff Typical hourglass deformity on frontal radiographs Extrathoracic tracheomalacia (from the site of a prior tracheostomy) demonstrate tracheal narrowing on inspiration Intrathoracic tracheomalacia (prior endotracheal intubation) have tracheal narrowing on expiration Wegeners granulomatosis Tracheal narrowing + upper airway and renal involvement + biopsy Tx: Cyclophosphamide therapy
Endotracheal and endobronchial TB
Usually associated with cavitary TB Production of large volumes of infected sputum predisposes to tracheal and central bronchial infection Tracheal scleroma infection with Klebsiella rhinoscleromatis Chronic phase, intense granulation tissue and fibrosis lead to stenosis of the nasal cavity, pharynx, larynx, and upper trachea Upper trachea shows irregular nodular narrowing, which may extend to involve the length of the trachea Biopsy: granulation tissue containing large foamy histiocytes filled with the causative organism (Mikulicz cells) Tx: Antibiotic therapy Focal tracheal dilatation Caused by congenital or acquired abnormalities of the elastic membrane or cartilaginous rings of the trachea. Localized tracheal dilatation may be seen with tracheoceles, with acquired tracheomalacia related to prolonged endotracheal intubation, or as a result of tracheal traction from severe unilateral upper lobe parenchymal scarring Diffuse Tracheal Disease Diffuse Tracheal Narrowing Congenital tracheal stenosis Rare incomplete septation of the cartilage rings, Napkin ring trachea = long segment tracheal narrowing Often associated with other congenital cardiovascular anomalies Anomalous origin of the left PA from the right PA (PA sling) Anomalous origin of the right upper lobe bronchus from the trachea (tracheal bronchus or bronchus suis). Saber-sheath trachea Fixed deformity of the intrathoracic trachea Coronal diameter is diminished to less than two-thirds of the sagittal diameter. Tracheal wall is uniformly thickened Calcification of the cartilaginous rings is present in most cases. Exclusively affects older men with functional evidence of chronic obstructive pulmonary disease. Amyloidosis Deposition of a fibrillar proteinpolysaccharide complex in various organs. Mass-like circumferential deposits that irregularly narrow the tracheal lumen are best demonstrated on CT and can result in recurrent atelectasis and pneumonia. Diagnosis is made by the presence of typical proteinpolysaccharide deposits demonstrated following Congo red staining of tracheal or bronchial wall biopsy specimens. Apple-green birefringence when viewed under polarized light Tracheobronchopathia osteochondroplastica Rare Characterized by the presence of multiple submucosal osseous and cartilaginous deposits within the trachea and central bronchi of elderly men Diagnosis is generally made on bronchoscopy and CT Calcified plaques can be seen involving the anterior and lateral walls of the trachea. Sparing of the membranous posterior wall of the trachea, which lacks cartilage, is a helpful feature that distinguishes this entity from tracheobronchial amyloid Usually asymptomatic May have recurrent infection related to bronchial obstruction by the masses. Relapsing polychondritis Systemic autoimmune disorder that commonly affects the cartilage of the earlobes, nose, larynx, tracheobronchial tree, joints, and large elastic arteries. Respiratory complications secondary to involvement of the upper airway cartilage accounts for nearly50% of all deaths from this condition. Diagnosis: recurrent inflammation at two or more cartilaginous sites, Most commonly the pinnae of the ear (producing cauliflower ears) and the bridge of the nose (producing a saddlenose deformity). Radiographs and CT: diffuse smooth thickening of the wall of the trachea and central bronchi with narrowing of the lumen Diffuse Tracheal Dilatation Tracheobronchomegaly (MounierKuhn syndrome) Congenital disorder of the elastic and smooth muscle components of the tracheal wall Association with EhlersDanlos syndrome and cutis laxa Found almost exclusively in men under the age of 50. Abnormal compliance of the trachea and central bronchi leads to central bronchial collapse during coughing. Symptoms are indistinguishable from those associated with chronic bronchitis and bronchiectasis. On frontal radiographs, the trachea and central bronchi measure greater than 3.0 cm and 2.5 cm, respectively, in coronal diameter. The trachea has a corrugated appearance caused by the herniation of tracheal mucosa and submucosa between the tracheal cartilages Tracheobronchomalacia (TBM) Congenital or acquired defect of tracheal cartilage Congenital disorders Relapsing polychondritis EhlersDanlos syndrome Mucopolysaccharidosis Acquired TBM More common Most often the result of prolonged intubation, prior tracheostomy, and extrinsic tracheal compression by mediastinal masses and vascular anomalies Imaging: excessive airway collapse on expiration, seen best on CT performed at total lung capacity (i.e., inspiration) A reduction in the cross-sectional area of the trachea exceeding 50% on the expiratory CT, particularly if there is a crescentic frown-like configuration to the trachea in cross section, is strongly suggestive Tracheal and Bronchial Injury Most often seen with blunt chest trauma from a deceleration-type injury Concomitant aortic laceration, great vessel injury, or rib (particularly an upper anterior rib), sternum, scapula, or vertebral fracture is the rule Mechanism: forceful compression of the central tracheobronchial tree against the thoracic spine during impact Proximal main bronchi (80%) or distal trachea (15%) within 2 cm of the tracheal carina; the peripheral bronchi are involved in 5% of cases. Most common form: Horizontal laceration or transection parallel to the tracheobronchial cartilage Early chest radiographs: presence of pneumothorax and pneumomediastinum, particularly in a patient not receiving mechanical ventilation Pneumothorax fails to respond to chest tube drainage owing to a large air leak at the site of airway interruption Subtended lung remains collapsed against the lateral chest wall (fallen lung sign) Aberrant endotracheal tube or an overdistended balloon cuff is a further clue Definitive diagnosis is by bronchoscopy MDCT with three-dimensional reconstruction with shaded surface display may be useful in patients who develop bronchial occlusion or stenosis because of a delay in diagnosis
Penetrating tracheal injuries usually involve the cervical trachea
Result from gunshot or stab wounds to the neck. Injury to the intrathoracic trachea is usually associated with fatal penetrating cardiovascular injury Broncholithiasis