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Large Airway Disease
Tracheal Disorders
Post-Traumatic Strictures
Definition
These are usually secondary to damage from external neck trauma or from a cuffed endotracheal or tracheostomy tube
CXR/CT
A focus of circumferential or eccentric tracheal narrowing associated with a segment of increased soft tissue
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Postintubation stenosis: this extends for several cm ▸ it typically involves the trachea above the level of the thoracic inlet
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Post-tracheostomy stenosis: this typically begins 1–1.5 cm distal to the inferior margin of the tracheostomy stoma ▸ it involves 1.5–2.5 cm of tracheal wall
Infectious Tracheobronchitis
Definition
This is most commonly due to a bacterial tracheitis in immunocompromised patients ▸ it is also seen with TB, rhinoscleroma and necrotizing invasive aspergillosis
CT
Irregular and circumferential tracheobronchial thickening ± mediastinitis
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Active phase: a narrowed and irregularly thickened trachea ± the main bronchi
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Fibrotic/healed phase: a narrowed trachea with a smooth wall of normal thickness
Tracheobronchial Fistula and Dehiscence
Bronchopleural fistula
This is most commonly caused by a necrotizing pneumonia or secondary to trauma
Nodobronchial/nodobroncho-oesophageal fistula
This is commonly caused by Mycobacterium tuberculosis ▸ it is characterized by gas within a cavitated hilar or mediastinal lymphadenopathy
Tracheo-oesophageal fistulas
The most common cause is a malignant neoplasia (particularly oesophageal) ▸ infection and trauma are other causes
Tracheal Neoplasms
Benign
Definition
This is most commonly a hamartoma, leiomyoma, neurogenic tumour or lipoma
CT
A well-demarcated and round lesion (< 2 cm) ▸ a smoothly marginated intraluminal polyp (hamartomas and lipomas may demonstrate fat attenuation)
Malignant
Definition
These are uncommon – the vast majority are a squamous cell or adenoid cystic carcinoma
CT
A soft tissue mass (usually involving the posterior and lateral walls) ▸ it is often sessile and eccentric resulting in asymmetrical luminal narrowing ▸ can be polypoid and mostly intraluminal (with mediastinal extension seen in 30–40%)
Secondary malignant neoplasms
Definition
These can be due to a haematogenous metastasis (commonly renal cell carcinoma and melanoma) or following direct local invasion
CT
Intraluminal soft tissue nodules and wall thickening
Tracheobronchial Papillomatosis
Definition
This is caused by human papillomavirus infection (and usually acquired at birth from an infected mother) ▸ it usually involves the larynx – occasionally extension into the trachea and proximal bronchi is seen
CT
Typically multiple small nodules projecting into the airway lumen or diffuse nodular thickening of the airway wall ▸ although benign it may undergo transformation to a squamous cell carcinoma
Tracheobronchomalacia
Definition
This results from weakened tracheal cartilage rings ▸ It is seen in association with tracheobronchomegaly, COPD, relapsing polychondritis and following trauma
CT
Luminal diameter narrowing > 70% on expiration compared with inspiration ▸ calibre changes >50% can be seen at expiration with normal tracheal compliance with high dynamic pressure gradients (e.g. COPD) ▸ a coronal tracheal diameter significantly larger than the sagittal diameter (producing a lunate configuration)
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Central tracheobronchial tree involvement may be either diffuse or focal
Anca-Associated Granulomatous Vasculitis
Definition
Large airway involvement is common (± subglottic or bronchial stenosis, ulceration and pseudotumour formation)
CT
Thickening of the subglottic region and proximal trachea (smooth symmetrical or asymmetrical narrowing over a variable length) ▸ nodular or polypoid lesions may be seen on the inner airway contour ▸ luminal stenosis may affect any main, lobar or segmental bronchus
Relapsing Polychondritis
Definition
A rare systemic autoimmune disease affecting the cartilage of the ears, nose, joints and tracheobronchial tree (inflammation is followed by fibrosis) ▸ usually there is a symmetrical subglottic stenosis – with disease progression the distal trachea and bronchi may become involved
CT
Smooth airway wall thickening associated with diffuse narrowing ▸ early sparing of the posterior tracheal wall (circumferential involvement with advanced disease) ▸ the trachea may become flaccid with considerable collapse at expiration ▸ fibrotic cartilaginous ring destruction may cause stenosis
Tracheal Disorders
Tracheobronchial Amyloidosis
Definition
This is seen in association with systemic amyloidosis or as an isolated manifestation – therefore it can form either multifocal or diffuse submucosal plaques or masses (with an intact overlying mucosa) ▸ dystrophic calcification or ossification is frequently present
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