Imaging Pearls ❯ Chest ❯ Trachea
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- “Large-airway pathological conditions are a heterogeneous group of diseases that include focal and diffuse lesions. Although tracheobronchial neoplasms are uncommon, there is a high incidence of malignancy. Furthermore, most of the benign neoplasms and inflammatory conditions are usually symptomatic and need treatment. Focal lesions may be subdivided into benign neoplasms (papilloma, hamartoma, and carcinoid), malignant neoplasms (squamous cell carcinoma, adenoid cystic carcinoma, other primary neoplasms such as lymphoma or haemangiopericytoma, and secondary malignancy), and non-neoplastic conditions (tuberculosis, post-intubation stenosis, idiopathic subglottic stenosis, post-inflammatory pseudotumour, trauma, and foreign body).”
Central airway pathology: clinic features, CT findings with pathologic and virtual endoscopy correlation
Daniel Barnes et al.
Insights Imaging (2017) 8:255–270 - "Diffuse lesions can be classified into lesions with dilatation of the tracheobronchial lumen (Mounier- Kuhn syndrome and acquired tracheobronchomegaly), lesions with stenosis (rhinoscleromatosis, granulomatous bronchitis, amyloidosis, sarcoidosis, granulomatosis with polyangitis, relapsing polychondritis, osteochondroplastic tracheobronchopathy), and lesions with respiratory collapse (tracheobronchomalacia).”
Central airway pathology: clinic features, CT findings with pathologic and virtual endoscopy correlation
Daniel Barnes et al.
Insights Imaging (2017) 8:255–270 - "Adenoid cystic carcinoma This is the second most common tracheal malignancy after squamous cell carcinoma, and it is the most common tumour of salivary glands in the large airways. This tumour has no relation with smoking. The patients are generally younger than 40 years of age, and there is no difference in gender distribution.”
Central airway pathology: clinic features, CT findings with pathologic and virtual endoscopy correlation
Daniel Barnes et al.
Insights Imaging (2017) 8:255–270 - "Adenoid cystic carcinoma arises most frequently in the lower trachea and main bronchi and has predominantly submucosal extension, appearing as a lesion with a smooth contour and intact mucosa at direct bronchoscopy. CT shows a smooth mass with endoluminal and extraluminal growth, and soft tissue attenuation, which usually involves more than 180 degrees of the airway circumference and often encircles the lumen.”
Central airway pathology: clinic features, CT findings with pathologic and virtual endoscopy correlation
Daniel Barnes et al.
Insights Imaging (2017) 8:255–270 - “Congenital tracheobronchomegaly is defined as significant dilation of the large airway, affecting the trachea and bronchi up to the fourth branch, secondary to severe atrophy of the longitudinal elastic fibres and thinning of the muscularis mucosa of the affected segments. Typically, the diagnosis is made in males between 20 and 40 years of age with a history of recurrent pulmonary infections. Although most of the cases are sporadic, a familial susceptibility exists, and the syndrome has been associated with connective-tissue diseases, such as Ehlers-Danlos in adults or cutis laxa in children.”
Central airway pathology: clinic features, CT findings with pathologic and virtual endoscopy correlation
Daniel Barnes et al.
Insights Imaging (2017) 8:255–270 - "CT shows diffuse and symmetrical dilatation of the large airway, generally a tracheal diameter greater than 3 cm and main bronchi diameter greater than 2.4 cm, associated with central bronchiectasis. Expiratory collapse is common, and the presence of tracheal diverticula gives the trachea a corrugated appearance.”
Central airway pathology: clinic features, CT findings with pathologic and virtual endoscopy correlation
Daniel Barnes et al.
Insights Imaging (2017) 8:255–270 - "Rhinoscleroma is a chronic, slowly progressive inflammatory disease of the upper respiratory tract, secondary to Klebsiella rhinoscleromatis infection. Rhinoscleroma is found predominantly in rural areas with poor socioeconomic conditions, where infection is facilitated by crowding and poor hygiene and malnutrition.”
Central airway pathology: clinic features, CT findings with pathologic and virtual endoscopy correlation
Daniel Barnes et al.
Insights Imaging (2017) 8:255–270 - "Relapsing polychondritis is a systemic disease, characterised by recurrent episodes of cartilaginous inflammation that lead to cartilage destruction. The disease is characterised by a chondral and perichondral inflammation secondary to an immune-mediated reaction of unknown cause, which implies antibodies against extracellular matrix components such as collagen type II and matrilin 1. At the time of diagnosis, the respiratory tract involves only 10% of the patients, but in the course of the disease it occurs in up to 50%. Although the disease affects men and women equally, the airway affectation is more common in women. Involvement of the respiratory tract carries a poor prognosis, and mortality is usually secondary to pneumonia.”
Central airway pathology: clinic features, CT findings with pathologic and virtual endoscopy correlation
Daniel Barnes et al.
Insights Imaging (2017) 8:255–270 - "CT shows increased attenuation and thickening of the tracheobronchial wall, with or without mural calcifications, and sparing of the posterior membranous wall. At a later stage, fibrosis leads to luminal irregular narrowing, and loss of the structural support of the cartilage leads to tracheobronchomalacia, which is seen as tracheobronchial collapse and air trapping on the expiratory CT scan.”
Central airway pathology: clinic features, CT findings with pathologic and virtual endoscopy correlation
Daniel Barnes et al.
Insights Imaging (2017) 8:255–270 - Focal Lesions: Benign Neoplasms
- Papilloma
- Hamartoma
- Carcinoid - Focal Lesions: Malignant Neoplasms
- Squamous cell carcinoma (SCC)
- Adenoid cystic carcinoma
- Haemangiopericytoma
- Lymphoma
- Metastases - Focal Lesions: Non-neoplastic lesions
- Tracheobronchial tuberculosis
- Post-intubation stenosis
- Idiopathic tracheal stenosis
- Inflammatory pseudotumour
- Foreign body aspiration
- Tracheobronchial trauma - Diffuse lesions: Non-neoplastic lesions
- Mounier-Kuhn syndrome
- Acquired tracheobronchomegaly
- Rhinoscleromatosis
- Amyloidosis
- Granulomatosis with polyangitis
- Sarcoidosis
- Relapsing polychondritis
- Tracheobronchopathia osteochondroplastica
- Tracheobronchomalacia - Trachea Filling Defect-Differential Dx
- Primary/Secondary
- True/Pseudo
- Benign or malignant
- Single/Multiple - Trachea Filling Defect-Differential Dx
- Pseudotumor, foreign body, web
- Primary malignancy-squamous, adenoid cystic
- Primary Benign-Hemangioma, papilloma, chondroma, fibrovascular Polyp
- Direct invasion-bronchogenic, esophagus, thryoid
- Multiple –Metastasis/Laryngotracheal papillomatosis - Diffuse Narrowing of the Trachea or Main Bronchi
- Relapsing polychondritis
- Amyloidosis
- Sarcoidosis
- Wegener’s granulomatosis
- Tracheopathia osteochondroplastica
- Carcinoma
- Infection (TB, histoplasmosis, coccidiomycosis) - Wegener Granulomatosis: Facts
- Necrotizing vasculitis that involves small to medium vessels
- May involve ear, nose, throat, lung or kidneys
- Clinical presentation ranges from sinusitis to cough, fever, wheezing to hematuria - Wegener Granulomatosis: Facts
- Upper airways involved in up to 92% of cases, renal in 80% and joints in 67%
- Age at dx usually 40-55 yrs
- M=F but females have airway problems more commonly
- Treatment with steroids and cyclophosphamide - Wegener Granulomatosis: Chest
- Cavitary nodules
- Large airway stenosis
- Nodules 1-10 cm in size
- Consolidation with or w/o hemorrhage
- Subglottic stenosis
- Adenopathy uncommon - MDCT of the Airways
- Narrowing of the Airway
-- Tumor
-- Infection
-- Trauma
-- Extrinsic Compression by normal structure (enlarged thyroid gland or vascular anomaly) - Nonneoplastic Lesions of the Trachea: Diffuse Disease
- Wegener granulomatosis
- Relapsing polychondritis
- Tracheobronchopathia osteochondroplastica
- Amyloidosis
- Papillomatosis
- Rhinoscleroma - Tracheal Papillomatosis: Facts
- More common in children
- Occurs in 5% of patients with laryngeal papillomatosis
- May be single or multiple
- Airway obstruction may lead to atelectasis, air trapping, postobstructive infection or bronchiectasis - Tracheopathia Osteochondroplastica: Facts
- TPO is an uncommon, benign, but slowly progressive disease of unknown etiology. It is characterized by endoluminal projection of cartilaginous and bony nodules arising in the submucosa of the trachea. Involvement may extend to lobar or segmental bronchi. TPO should be considered in cases where cough, dyspnea, persistent pulmonary infection, hoarseness, or recurrent hemoptysis remain after appropriate treatment of other presumptive underlying causes. - Pulmonary Sling: Facts
- Left pulmonary aa arises from the right pulmonary aa and passes between the trachea and esophagus
- Tracheobronchiomalacia and/or stenosis can occur in up to 50% of cases - Diffuse Narrowing of the Trachea or Main Bronchi
- Relapsing polychondritis
- Amyloidosis
- Sarcoidosis
- Wegener’s granulomatosis
- Tracheopathia osteochondroplastica
- Carcinoma
- Infection (TB, histoplasmosis, coccidiomycosis) - Nonneoplastic Lesions of the Trachea: Focal Disease
- Postintubation stenosis
- Postinfectious stenosis
- Posttransplantation stenosis
- Systemic diseases that involve the airway
-- Crohn disease
-- Sarcoidosis
-- Behcet syndrome - Nonneoplastic Lesions of the Trachea: Diffuse Disease
- Wegener granulomatosis
- Relapsing polychondritis
- Tracheobronchopathia osteochondroplastica
- Amyloidosis
- Papillomatosis
- rhinoscleroma - Tracheal Papillomatosis: Facts
- Drop lesions may cavitate
- Laser treatment common but lesions often recur
- Malignant degeneration to squammous cell carcinoma occurs in up to 10% of adult cases - Rhinoscleroma
- Rhinoscleroma (RS) is a chronic, slowly progressive granulomatous infection of the upper airways caused by Klebsiella sp: first described by Von Hebra - 1870
- Endemic in tropical/subtropical areas with > 80% reported 5 endemic foci: Mexico, South and Central America; Africa (5%), Indonesia; Eastern Europe
- Infection via person to person transmission; typically affects lower socioeconimic groups, esp. rural communities
- Sporadic occurrence in US: 6 cases in 1993 - Rhinoscleroma
- RS usually affects pts 20-30 yrs old; > women
- Prediliction for the nasal cavity (> 95%); pharynx 18-43%; trachea – 12%; bronchi 5%
- Stage 1: catarrhal phase – purulent inflammation
- Stage 2: atrophic stage – crusting leading to friable membranes prone to bleed
- Stage 3: granulomatous phase – with proliferating nodules and masses
- Stage 4: sclerosing phase
- “Plastic bronchitis denotes the formation and expectoration of branching, mucoid bronchial casts that can be astonishingly large. The branching pattern may match the bronchial distribution of an entire lobe or lung. Although the condition is usually a sign of an underlying bronchopulmonary disorder such as asthma or allergy, the cause of cast formation remains an enigma in some cases. In the older literature plastic bronchitis also was called fibrinous bronchitis, and in the 19th and early part of the 20th centuries it seems to have been much more prevalent than it is today.”
Plastic Bronchitis: Large, Branching, Mucoid Bronchial Casts in Children
Bowen AD et al
AJR 144:371-375 - "The clinical presentation has productive cough, dyspnea, pleuritic chest pain, fever, and wheezing. Radiographic evaluation reveals the site of the bronchial cast impaction, demonstrating atelectasis or infiltrates. Hyperinflation is often evident on the contralateral side. The CT scan allows visualization of impacted casts within the major airways.”
A Rare Case of Idiopathic Plastic Bronchitis Mohammed
Raoufi et al.
Case Reports in Pulmonology Volume 2017, Article ID 4789751
- “Bronchogenic cysts are congenital lesions thought to result from abnormal budding of the embryonic foregut. At computed tomography (CT), bronchogenic cysts typically manifest as spherical masses of either water or soft-tissue attenuation. When bronchogenic cysts manifest as water-attenuation masses on CT scans, differentiation from other mediastinal processes such as lymphadenopathy or neoplasia is not difficult. However, when bronchogenic cysts manifest as soft-tissue–attenuation masses on CT scans, differentiation from solid lesions can be more problematic.”
Bronchogenic Cyst: Imaging Features with Clinical and Histopathologic Correlation
McAdams HP et al.
Radiology 2000 217:2, 441-446 - “The fluid within bronchogenic cysts is usually a mixture of water and proteinaceous mucus. The contents of the cysts in our series were not chemically analyzed. However, descriptions of the fluid ranged from a thin, watery liquid to hemorrhagic fluid to a very viscous, mucoid material. This variability in cyst content is likely responsible for the variability of attenuation seen on CT scans and signal intensity characteristics seen on MR images.”
Bronchogenic Cyst: Imaging Features with Clinical and Histopathologic Correlation
McAdams HP et al.
Radiology 2000 217:2, 441-446 - “Appropriate treatment of patients with bronchogenic cysts depends on the patient’s age and symptoms at presentation. Symptomatic cysts should be resected (either at thoracotomy or by means of video-assisted thoracoscopy) regardless of patient age, unless surgical risks are unacceptably.”
Bronchogenic Cyst: Imaging Features with Clinical and Histopathologic Correlation
McAdams HP et al.
Radiology 2000 217:2, 441-446
- “ The normal coronal tracheal dimension ranges from 13 to 25 mm in men and from 10 to 21 mm in woman, and the sagittal diameter from 13 to 27 mm in men and from 10 to 23 mm in woman.”
Tumors and Tumorlike Conditions of the Large Airways
Ngo AVH et al.
AJR 2013; 201:301-313 - “ Ninety percent of all adult tracheal tumors are malignant; squammous cell carcinoma (SCC) is the most common tracheal tumor.”
Tumors and Tumorlike Conditions of the Large Airways
Ngo AVH et al.
AJR 2013; 201:301-313 - “ The most common airway tumor in adolescents and young adults is endobronchial carcinoid tumor.It arises in the central bronchi and may cause obstruction.”
Tumors and Tumorlike Conditions of the Large Airways
Ngo AVH et al.
AJR 2013; 201:301-313 - “ Mucoepidermoid carcinoma (MEC) is rare, representing only 0.1-0.2% of all thoracic malignancies. It arises from minor salivary glands and most commonly originates in lobar or segmental bronchi. More than half of patients are younger than 30 years old.”
Tumors and Tumorlike Conditions of the Large Airways
Ngo AVH et al.
AJR 2013; 201:301-313 - Focal Lesion of the Airways
- Squammous cell carcinoma
- Adenoid cystic carcinoma
- Carcinoid
- Hamartoma
- Mucoepidermoid carcinoma
- Foreign body
- metastases - Diffuse Lesions of the Airways
- Relapsing polychondritis
- Tracheobrochopathia osteochondroplastica
- Wegener granulomatosis
- Adenoid cystic carcinoma
- Infection
- Amyloidosis
- Papillomatosis
- “In the last 10 years, on a total of 55 patients treated in our institution for benign lesions of the major airway, 20 were with an acute injury; eleven females and nine males with a mean age of 58 years (range of 24–92). Twelve lesions were iatrogenic (orotracheal intubation) and eight were post-traumatic (three blunt traumas, five penetrating traumas). The cervical trachea was involved in 13 cases (one associated to an incomplete esophageal transection and two associated to laryngeal injuries), the thoracic trachea in six cases (four extended to the right mainstem one and to the left).”
Acute major airway injuries: clinical features and management
Mussi A et al.
European j Cardio-Thoracic Surg
Vol 20, issue 1, July 2001; pages 46-52 - “Tracheobronchial injuries are relatively uncommon, often require a degree of clinical suspicion to make the diagnosis, and usually require immediate management. Most penetrating injuries occur in the cervical area. Most blunt injuries occur in the distal trachea or right mainstem, and are best approached by a right posterolateral thoracotomy.”
Traumatic Injury to the Trachea and Bronchus
Karmy-Jones R, Wood DE
Thorac Surg Clin
2007 Feb; 17(1):35-46 - “Tracheobronchial injuries are relatively uncommon, often require a degree of clinical suspicion to make the diagnosis, and usually require immediate management. The primary initial goals are twofold: stabilize the airway and define the extent and location of injury. These are often facilitated by flexible bronchoscopy, in the hands of a surgeon capable of managing these injuries. Most penetrating injuries occur in the cervical area. Most blunt injuries occur in the distal trachea or right mainstem, and are best approached by a right posterolateral thoracotomy.”
Traumatic Injury to the Trachea and Bronchus
Karmy-Jones R, Wood DE
Thorac Surg Clin
2007 Feb; 17(1):35-46 - Churg Strauss Syndrome Dx made by vasculitis at biopsy and at least four of the following criteria
- Asthma
- Blood eosinophilia (>10% of total WBC count)
- Mono or polyneuropathy
- Nonfixed pulmonary infiltrates
- Sinus abnormality
- Extravascular eosinophils as seen on a bx specimen - Tracheobronchial Cartilage Calcification: Etiologies
- Idiopathic
- Congenital cardiovascular disease
- Keutel syndrome
- Chondroplasia punctata
- Warfarin embryopathy
- Warfarin sodium therapy - Tracheobronchial Calcification: Warfarin therapy
"As more CT examinations are performed on younger patients receiving warfarin, more cases of tracheobronchial calcification will be seen. Radiologists should realize that this finding is not normal in pediatric or young adult patients and should be aware of its association with warfarin sodium therapy."
CT Detection of Tracheobronchial Calcification in an 18-Year-Old on Maintenance Warfarin Sodium Therapy
Joshi A et al
AJR 2000;175:921-922 - Peripheral Pulmonary Stenosis: Differential Dx
- Newborns yet intervention rarely needed
- Rubella syndrome- tapering of pulmonary arteries from origin distally
- Noonan’s syndrome
- William’s syndrome
- Keutel syndrome - Dx: Keutel Syndrome
In 1972, Keutel [1] described a new malformative syndrome, characterized by diffuse and abnormal cartilage calcification, brachytelephalangism, hearing loss and pulmonary stenosis. - "Most tumors of the tracheobronchial tree are malignant. Benign tumors are quite rare (1.9% of all lung tumors). Unlike malignant tumors, many benign neoplasms are slow growing and present with symptoms related to bronchial obstruction."
Benign Tumors of the Tracheobronchial Tree: CT-Pathologic Correlation
Ko JM et al.
AJR 2006; 186:1304-1313 - Benign Tumors of the Tracheobronchial Tree: Differential Dx
- Hamartoma
- Leiomyoma
- Lipoma
- Neurogenic tumor
- Inflammatory polyp (fibroepithelial polyp)
- Amyloidoma
- Papilloma
- Pleomorphic adenoma - Benign Tumors of the Tracheobronchial Tree: Facts
- Up to 77% of benign tumors are hamartomas
- Post obstructive changes in the lung are common
- Hemoptysis common clinical presentation
- Leiomyoma usually arise in lower third of the trachea where there is more smooth muscle
- Lesions may have fat or calcification - Diffuse Narrowing of the Trachea or Main Bronchi
- Relapsing polychondritis
- Amyloidosis
- Sarcoidosis
- Wegener’s granulomatosis
- Tracheopathia osteochondroplastica
- Carcinoma
- Infection (TB, histoplasmosis, coccidiomycosis) - Non Neoplastic Lesions of the Trachea: Focal Disease
- Postintubation stenosis
- Postinfectious stenosis
- Posttransplantation stenosis
- Systemic diseases that involve the airway: Crohn's Disease, Sarcoidosis, and Behcet syndrome - Non Neoplastic Lesions of the Trachea: Diffuse Disease
- Wegener granulomatosis
- Relapsing polychondritis
- Tracheobronchopathia osteochondroplastica
- Amyloidosis
- Papillomatosis
- Rhinoscleroma - Tracheal Papillomatosis: Facts
- More common in children
- Occurs in 5% of patients with laryngeal papillomatosis
- May be single or multiple
- Airway obstruction may lead to atelectasis, air trapping, postobstructive infection or bronchiectasis - Tracheal Papillomatosis: Facts
- Drop lesions may cavitate
- Laser treatment common but lesions often recur
- Malignant degeneration to squammous cell carcinoma occurs in up to 10% of adult cases - Airway Stent Complications
- Malpositioning
- Migration
- Size discrepancy between airway and stent
- Excessive granulation tissue
- Stent fracture - "Computed tomography (CT) plays an important role in aiding planning of stent placement and in detecting various stent complications."
Multislice CT Evaluation of Airway Stents
Lee KS et al. J Thor imaging 2005;20:81-88