Anomaly Tracheobronchial Tree - RD+SKR

Literature Reading
ANOMALIES OF
TRACHEOBRONCHIAL
TREE
Radian N
SUPERVISOR :
dr. Denese MS Rully, Mkes, SpTHT-KL
Department of Otorhinolaryngology-Head & Neck Surgery

Faculty of Medicine Padjadjaran University
Hasan Sadikin General Hospital
Bandung
2014
Introduction
Congenital anomalies of the chest are an
important cause of morbidity in infants,
children, and even adults.
The evaluation of affected patients
frequently requires multiple imaging
modalities to diagnose the anomaly and
plan surgical correction.
Wooten, C.T. & Myer, C.M. 2014. Congenital Aerodigestive Tract Anomalies. In Johnson, J.T. & Rosen, C.A. (ed).Baileys Head & Neck Surgery
Otolaryngology 5th ed. p. 1340-1361. Baltimore : Lippincott Williams & Wilkins
Embryology
The respiratory system
ventral wall of the foregut
34 weeks (embryonic stage)
The tracheobronchial tree develops between days 24 and
36 of gestation.
The separation of alimentary and respiratory structures is
not always completed successfully
congenital
Sadler, T.W. 2010, Langmans Medical Embryology 8th ed.

Montana : Twin Bridges
Tracheobronchial Anomalies
A. Tracheomalacia
B. Tracheal Stenosis
C. Tracheoesophageal fistula
D. Tracheal Bronchus
E. Bronchial Atresia
F. Bronchogenic Cyst
A. Tracheomalacia
Tracheal wall softening due to an abnormality
of the cartilaginous ring and hypotonia of the
myoelastic element
Tracheomalacia can be categorized into 2
groups
1. Primary tracheomalacia
2. Secondary tracheomalacia (innominate artery
compression, aortic compression, vascular rings, a
pulmonary artery
sling )
A. Tracheomalacia
History
Infants expiratory stridor
Feeding difficulties are reported sometimes.
Hoarseness, aphonia, and difficulty in
breathing also may be reported.
Obtain history of an acquired etiology such
as chest trauma, recurrent tracheobronchitis,
cartilage disorder (relapsing polychondritis),
and lung resection.
A. Tracheomalacia
Physical examination
Inspiratory retractions of supraclavicular
and intercostal
Thoracic deformity chronic
tracheomalacia
Auscultation reveals normal inspiration but
abnormal expiratory noises.
Not uncommonly, infants growth failure.
A. Tracheomalacia
Imaging Studies
Chest radiograph narrowing of the tracheal lumen
during expiration
Dynamic expiratory CT elicits a larger degree of
airway collapse than standard end-expiratory CT in
patients with tracheobronchomalacia.
A. Tracheomalacia
Healthy trachea is visualized

endoscopically.
Tracheomalacia.
Otolaryngology 5th ed. P. 1340-1361. Baltimore : Lippincott Williams & Wilkins
A. Tracheomalacia
Radiograph of the trachea in a

2-month-old infant with stridor
shows marked diffuse tracheal
narrowing during expiration
(arrows).
The Department of Pediatric Radiology, Hospital Infantil La Paz
10
A. Tracheomalacia
Radiographs of a 3-week-old infant with Hurler disease. The

trachea (arrows) was noted to be persistently narrowed in all
studies.
11
A. Tracheomalacia
Medical therapy
Conservative management, consisting of
humidified air, chest physical therapy, slow
and careful feedings, and control of
infection and secretions with antibiotics.
Surgical therapy
A.Tracheostomy
B.Aortopexy
12
Future And Controversies

ENDOTRACHEAL AND ENDOBRONCHIAL
STENTING
Stents for angioplasty Palmaz Stents placed
through a bronchoscope
The stainless steel, balloon expandable stents
come in a variety of sizes
13
Case Study
CASE 1: Three month old baby with complex congenital heart
disease, unable to extubate secondary to severe collapse (malacia)
and extrinsic compression of distal trachea (Figure 1). Palmaz
stent inserted endoscopically to stent trachea (Figure 2). View of
carina from within stented trachea (Figure 3). Immediate
extubation was made possible.
Figure 1:
Collapse of distal
Figure 2: Palmaz
stent in situ.
Figure 3:
14
Excellent patency
Case Study
CASE 2: 8 month old with collapsed left lung secondary to complete
extrinsic compression of left main bronchus following cardiac
transplantation (Figures 1,2 and 4). Vascular pexy failed to
alleviate problem. Palmaz stent inserted into left main bronchus with
immediate re-expansion of lung (Figure 3).
Figure 1. CXR
showing complete
collapse of of left
lung
Figure 2. Still
collapse despite
intubation and
positive pressure
Figure 3. Reexpansion of lung

following insertion of
15
Palmaz stent into left
Case Study
Figure 4. Photo of
collapsed left main
bronchus. Also small
suction induced
granuloma of carina
noted.
Figure 5. Palmaz
stent in left main
bronchus achieving
excellent patency.
Figure 6. View from

within stent showing
distal patency of left
upper and left lower
bronchi.
16
Congenital tracheal stenosis rare
Presence of focal or diffuse complete
tracheal cartilage rings, resulting in a
fixed tracheal narrowing.
Usually present stridor and/or pneumonia.
Variety of congenital stenosis :
50% focal,
30% generalized
20% funnel-shaped
17
Laryngotracheopulmonary
specimen at autopsy of
neonate with congenital
tracheal stenosis
(viewed from posterior).
Note the funneling of the
trachea and the complete
tracheal rings in the stenotic
segment.
18
Bronchoscope not
able to pass into the
upper trachea.
19
Tracheal Stenosis
Imaging
Studies
Neck soft tissue x-ray
Computed axial
tomography (CT
scan)
MRI
20
(a) Posteroanterior
(b) lateral radiographs show narrowing

of the tracheal lumen in the subglottic
trachea (arrows).
21
c) Curvilinear coronal reformation of CT scan

d) Posteroanterior radiograph of the trachea
shows the narrowed segment (arrows) (1 =
in another patient, obtained with filtered
craniocaudal length of the stenosis, 2 =
high kilovoltage technique, shows two
transverse diameter of the tracheal lumen at
tracheal narrowings (arrows).
the stenosis).
22
Tracheal Stenosis
Operative correction
Segmental resection with end-to-end anastomosis
Tracheoplasty .
Cardiopulmonary by-pass is used by most
surgeons to ensure adequate oxygenation during
tracheoplasty.
23
C. Tracheoesophageal
Fistula
Congenital or acquired communication
between the trachea and esophagus.
Thomas Gibson 1697 infant with
esophageal atresia and a TEF
Tracheoesophageal fistula can be
categorized into 2 groups:
1. Congenital TEFs
2. Acquired TEFs
24
Fistula
25
Fistula
26
Fistula
History
Maternal polyhydramnion
Fine white frothy bubbles of mucus in the
mouth and nose.
Infants may develop rattling respiration
and episodes of coughing and choking in
association with cyanosis.
Cough, aspiration, and fever
27
Fistula
Physical examination
Abdominal distention collection of air in
the stomach
28
Fistula
Imaging Studies
Prenatal diagnosis of congenital TEFs: Prenatal
ultrasound may reveal :
Polyhydramnios
Absence of fluid-filled stomach
Small abdomen,
Lower-than-expected fetal weight,
Distended esophageal pouch.
29
Fistula
Postnatal diagnosis of congenital TEFs :
Plain chest radiographs Absence of a
gastric bubble ( esophageal atresia with a
proximal TEF )
CT scans
Flexible esophagoscopy or flexible
bronchoscopy may be useful in the
diagnosis of acquired TEFs
30
Fistula
Surgical Care
A. Congenital TEFs
Thoracotomy and the head of table is
elevated
A posterolateral thoracotomy incision is
made through the fourth intercostal space
Tracheal suture line may be covered with a
flap of mediastinal pleura.
If a fistula lies between the esophageal pouch and

trachea, the esophageal anastomosis is performed
in 1-2 layers and is covered with mediastinal pleura
31
Fistula
Surgical Care
B. Acquired TEFs
Can be performed by use of one or more
strap muscle detached superiorly and
rotated between the trachea and
esophagus at the site of fistula.
Alternatively, a portion of
sternocleidomastoid muscle rotated as a
pedicle, based either superiorly or inferiorly
32
Sandifort in 1785 a right upper bronchus
originating in the trachea
Exits the right lateral wall of the trachea
usually asymptomatic
Well diagnosed at chest CT as a small area of
hypoattenuation arising directly from the trachea
Bronchography and bronchoscopy allow the direct
visualization of the ectopic bronchus
33
(a) Drawing shows the most

frequent origin of the
tracheal bronchus (arrows).
34
(b) CT section demonstrates a

right-upper-lobe bronchus
(arrows) arising from the
trachea, above the carina.
(c) CT scan of the same

patient at the level of the
carina, 2 cm below the origin
of the tracheal bronchus.
35
d) Bronchogram
helps confirm the
diagnosis and
shows the origin
of the tracheal
bronchus
36
Most patients with tracheal bronchus can be
treated conservatively;
However, in symptomatic patients surgical
excision of the involved segment is necessary
37
Congenital bronchial atresia rare
A proximal segmental or subsegmental bronchus
that lacks communication with the central
airways.
The upper-lobe bronchi are more frequently
affected; middle and lower lobes are rarely
affected
The bronchi distal filled with mucus and form a
bronchocele.
38
History
50% of cases, mostly in young men,
asymptomatic
Newborn water-density mass
Childhood focal air trapping
Adults congenital lobar emphysema
39
Imaging studies
Chest radiographic bronchocele
CT scan
MRI
40
(a) CT scan shows air trapping

in the right upper lobe (arrows).
b) CT scan in the same patient

shows a round opacity at the site
of the atresia, medial to the air
trapping, representing mucoid
impaction just distal to the atresia.
41
Originate from the primitive ventral
foregut mediastinal, intrapulmonary,
or, less frequently, in the lower neck.
Two-thirds of the patients are
symptomatic compression of the
trachea or bronchi, which leads :
- cough
- stridor
- wheezing
- dyspnea
- cyanotic spells
- pneumonia
42
The cysts contain mucoid material lined by
ciliated columnar or cuboidal epithelium
Imaging studies
Chest radiograph water density mass
lession
CT scan
MRI
43
(a) Chest radiograph of an

asymptomatic 5-year-old girl
shows a large soft-tissue mass in
the right hemithorax (arrows).
(b) Contrast material-enhanced

CT scan through the upper lobes
shows a well-defined waterdensity homogeneous mass (*)
with no contrast enhancement.
44
a) Chest radiograph shows rounded

mass with an air-fluid level, occupying
the entire right middle lobe,
corresponding to a bronchogenic cyst
connecting with the bronchus.
(b) Contrast-enhanced CT scan shows a

thick-walled fluid-filled rounded mass (*)
with an air-fluid level, corresponding to
the infected bronchogenic cyst. Note
enhancement of the cystic wall.
45
Therapy
Surgical therapy :
1.Minimal invasive techniques thoracoscopy
2.Thoracotomy
46
Thoracoscopic view of a resected bronchogenic cyst

47
Highlights
Taken as a whole, congenital tracheobronchial tract
anomalies are relatively common.
Flexible and rigid endoscopy and selected radiographic
examinations are frequently required to augment a
careful history and physical examination in the
diagnosis of congenital tracheobronchial tract disease.
Modern tracheobronchial disease diagnosis and
treatment frequently takes place within a
multidisciplinary model, combining the expertise of
the otolaryngologist with pulmonologists,
gastroenterologists,speech pathologists, and other
aerodigestive related practitioners.
48
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Anomaly Tracheobronchial Tree - RD+SKR

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Literature Reading

Department of Otorhinolaryngology-Head & Neck Surgery

Sadler, T.W. 2010, Langmans Medical Embryology 8th ed.

Healthy trachea is visualized

Radiograph of the trachea in a

The Department of Pediatric Radiology, Hospital Infantil La Paz

Radiographs of a 3-week-old infant with Hurler disease. The

Future And Controversies

Figure 3. Reexpansion of lung

Figure 6. View from

(b) lateral radiographs show narrowing

The Department of Pediatric Radiology, Hospital Infantil La Paz

c) Curvilinear coronal reformation of CT scan

If a fistula lies between the esophageal pouch and

(a) Drawing shows the most

The Department of Pediatric Radiology, Hospital Infantil La Paz

(b) CT section demonstrates a

(c) CT scan of the same

The Department of Pediatric Radiology, Hospital Infantil La Paz

The Department of Pediatric Radiology, Hospital Infantil La Paz

(a) CT scan shows air trapping

b) CT scan in the same patient

The Department of Pediatric Radiology, Hospital Infantil La Paz

(a) Chest radiograph of an

(b) Contrast material-enhanced

The Department of Pediatric Radiology, Hospital Infantil La Paz

a) Chest radiograph shows rounded

(b) Contrast-enhanced CT scan shows a

The Department of Pediatric Radiology, Hospital Infantil La Paz

Thoracoscopic view of a resected bronchogenic cyst

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