Using CT to Diagnose Nonneoplastic Tracheal Abnormalities: Appearanceof the Tracheal Wall

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Using CT to Diagnose Nonneoplastic Tracheal Abnormalities

Appearanceof the Tracheal Wall

Emily M. Webb¹, Brett M. Elicker and W. Richard Webb

^¹ All authors: Department of Radiology, University of California, 505 Parnassus Ave., M396, San Francisco, CA 94143-0628.

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Fig. 1A. —Components of normal tracheal wall. Drawing shows horseshoe-shaped tracheal cartilage supporting anterior and lateral tracheal walls. Posterior tracheal membrane is thinner. Mucosa and submucosa internal to cartilage are thin and difficult to see on CT scan.

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Fig. 1B. —Components of normal tracheal wall. Histopathologic section shows horseshoe-shaped cartilage (large arrow) as dark. Posterior tracheal membrane (small arrows) is bowed anteriorly. (magnification, x2) (Courtesy of Warnock M, San Francisco, CA)

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Fig. 2A. —76-year-old woman with normal trachea. High-resolution CT scan shows anterior tracheal wall to be 1- to 2-mm thick. Note cartilaginous calcification. In locations of cartilaginous calcification, no soft tissue is seen internal to it. Posterior tracheal membrane, being thin, is difficult to distinguish from adjacent esophagus. At this level, trachea appears round.

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Fig. 2B. —76-year-old woman with normal trachea. High-resolution CT scan at level lower than A shows right posterolateral tracheal wall to be thin and outlined by lung. Trachea appears more oval at this level.

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Fig. 2C. —76-year-old woman with normal trachea. Expiratory high-resolution CT scan near level of B shows posterior tracheal membrane bowing forward in normal fashion. Note scant inward movement of lateral tracheal walls with expiration.

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Fig. 3. —82-year-old woman with dense calcification of tracheal cartilage. High-resolution CT scan shows calcified cartilage that appears to constitute entire tracheal wall. Posterior tracheal membrane, lacking cartilage, appears thin and uncalcified. Its relatively flattened contour is normal.

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Fig. 4A. —85-year-old man with history of chronic obstructive pulmonary disease and saber-sheath tracheal deformity. CT scan above thoracic inlet shows trachea to have normal contour. Calcification of cartilage is normal.

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Fig. 4B. —85-year-old man with history of chronic obstructive pulmonary disease and saber-sheath tracheal deformity. CT scan at thoracic inlet shows side-to-side narrowing of trachea. Tracheal cartilage is calcified. Tracheal wall is normal in thickness.

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Fig. 4C. —85-year-old man with history of chronic obstructive pulmonary disease and saber-sheath tracheal deformity. CT scan lower than B shows more severe tracheal narrowing in its sagittal dimension. Side-to-side narrowing of trachea at and below thoracic inlet, without thickening of tracheal wall, is typical of saber-sheath trachea.

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Fig. 4D. —85-year-old man with history of chronic obstructive pulmonary disease and saber-sheath tracheal deformity. Drawing shows typical appearance of saber-sheath trachea compared with normal trachea. Cartilage is shown as dark gray. Narrowing of trachea is caused by deformity of tracheal cartilage. Mucosa and submucosa are normal.

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Fig. 5A. —80-year-old man with acute tracheal stenosis representing granulation tissue after intubation. Three-millimeter collimated CT scan shows narrowing of tracheal lumen by increased thickness of soft tissue internal to tracheal cartilage and thickening of posterior tracheal membrane. Tracheal cartilage (arrows) is faintly calcified and appears normal in shape. Outer tracheal wall has normal configuration and trachea has normal oval shape.

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Fig. 5B. —80-year-old man with acute tracheal stenosis representing granulation tissue after intubation. On parasagittal reconstruction from 3-mm collimated CT scans, narrowing appears focal and hour-glass-shaped. Granulation tissue (arrow) is visible internal to calcified cartilage of anterior tracheal wall.

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Fig. 5C. —80-year-old man with acute tracheal stenosis representing granulation tissue after intubation. Drawing shows appearance of tracheal stenosis caused by granulation tissue compared with normal trachea. Soft tissue internal to tracheal cartilage is thickened.

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Fig. 6A. —66-year-old man with chronic tracheal stenosis after intubation. Three-millimeter collimated CT scan shows tracheal lumen narrowed primarily because of collapse and inward displacement of calcified tracheal cartilage. Lateral tracheal walls are displaced inward, similar to saber-sheath trachea in appearance. Slight thickening of mucosa and submucosa caused by granulation tissue or fibrosis is also visible internal to cartilage. This finding would not be expected in saber-sheath trachea. Expiratory images showed no further tracheal collapse.

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Fig. 6B. —66-year-old man with chronic tracheal stenosis after intubation. Drawing shows chronic tracheal stenosis, characterized by collapse of tracheal cartilage. Mucosa and submucosa may be normal or thickened.

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Fig. 7A. —55-year-old woman with Wegener's granulomatosis, lung nodules, and tracheal and bronchial involvement. CT scan with 7-mm collimation shows circumferential thickening of tracheal wall, with involvement of both cartilaginous (anterior and lateral) and membranous (posterior) portions.

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Fig. 7B. —55-year-old woman with Wegener's granulomatosis, lung nodules, and tracheal and bronchial involvement. CT scan with 7-mm collimation shows circumferential thickening of both right and left bronchial walls. Irregularity of mucosal surface suggests ulceration.

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Fig. 7C. —55-year-old woman with Wegener's granulomatosis, lung nodules, and tracheal and bronchial involvement. Drawing shows typical appearance of Wegener's granulomatosis. Mucosal and submucosal inflammation results in concentric thickening of tracheal wall and mucosal ulceration in some patients.

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Fig. 8A. —47-year-old man with tracheobronchial amyloidosis. CT scan shows smooth concentric tracheal wall thickening that involves posterior wall to lesser degree. Concentric submucosal calcification is seen along inner tracheal wall.

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Fig. 8B. —47-year-old man with tracheobronchial amyloidosis. CT scan shows concentric thickening and calcification of both main bronchi, typical of tracheobronchial amyloidosis. (Courtesy of Im JG, Seoul, Korea)

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Fig. 8C. —47-year-old man with tracheobronchial amyloidosis. Drawing shows typical appearance of tracheal amyloidosis. Submucosal deposits of amyloid result in concentric, smooth, or nodular thickening of tracheal wall. Calcification (shown as black) is common and may also be concentric.

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Fig. 9A. —64-year-old man with tracheobronchopathia osteochondroplastica. CT scan shows typical findings of this entity: irregular nodular areas of calcification (arrow) involving anterior and lateral (cartilaginous) portions of tracheal wall. Calcifications are much more irregular than those seen in healthy patients and result in irregular narrowing of tracheal lumen. (Courtesy of Müller NL, Vancouver, B. C.)

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Fig. 9B. —64-year-old man with tracheobronchopathia osteochondroplastica. Drawing shows typical appearance of tracheobronchopathia osteochondroplastica. Submucosal nodules of calcified cartilage occurring in relation to cartilage (shown in black) involve anterior and lateral tracheal walls. These nodules result in irregular inner tracheal wall.

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Fig. 10A. —44-year-old man with polychondritis and progressive shortness of breath on exertion. Inspiratory CT scan obtained with 3-mm collimation shows thickening of anterior and lateral tracheal walls caused by thickening of tracheal cartilage. Cartilage is partially calcified. Posterior tracheal wall is normal in thickness.

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Fig. 10B. —44-year-old man with polychondritis and progressive shortness of breath on exertion. CT scan through proximal main bronchi shows anterior bronchial wall thickening similar to that seen in A.

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Fig. 10C. —44-year-old man with polychondritis and progressive shortness of breath on exertion. Dynamic expiratory CT scan at same level as A shows marked tracheal narrowing on expiration.

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Fig. 10D. —44-year-old man with polychondritis and progressive shortness of breath on exertion. Drawing shows typical appearance of polychondritis. Anterior and lateral tracheal walls are thickened because of thickening of tracheal cartilage. Posterior membrane appears normal.

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Fig. 11. —50-year-old woman with polychondritis. Coronal reconstruction of CT scans shows involvement of both extrathoracic and intrathoracic trachea, characteristic of this disease. Note thickening of lateral tracheal walls (arrows).

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Fig. 12. —88-year-old man with tracheal diverticulum, detected incidentally. CT scan shows it to arise from posterolateral right tracheal wall (arrow) near thoracic inlet, posterior to tracheal cartilage. Communication with tracheal lumen is easily seen.

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Fig. 13. —57-year-old man with tracheobronchomegaly. CT scan shows tracheal wall to be thin, measuring 3.7 cm in diameter. Expiratory images were not obtained.

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