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Radiology of the trachea

Author
Paul Stark, MD
Section Editor
Nestor L Muller, MD, PhD
Deputy Editor
Geraldine Finlay, MD

INTRODUCTION

Most clinicians quickly recognize a variety of abnormal patterns of diffuse parenchymal lung disease on conventional chest radiographs. However, anomalies of the upper respiratory tract, some of which can cause acute respiratory failure, are often overlooked during the initial assessment. Imaging of the trachea will be reviewed here. The radiologic manifestations of diffuse parenchymal lung disease, and the management of central airway obstruction, are discussed separately. (See "Evaluation of diffuse lung disease by conventional chest radiography" and "Diagnosis and management of central airway obstruction".)

ANATOMY

The trachea extends from the lower border of the larynx (2 cm below the vocal cords) to the carina, where it bifurcates into the mainstem bronchi. The average tracheal length is 10 to 12 cm, and the normal angle of the tracheal bifurcation is 70 ± 20 degrees (image 1A-B). With deep inspiration, the tracheal length increases by as much as 2 cm and the angle of the tracheal bifurcation decreases by up to 10 degrees [1,2].The superior border of the manubrium sterni separates the extrathoracic cervical trachea from the intrathoracic trachea.

The trachea consists of four layers: an inner mucosal layer, a submucosal layer, cartilage, and muscle as well as an outer adventitia. It is supported anteriorly and laterally by 18 to 22 semicircular incomplete rings of cartilage connected by annular ligaments of fibroconnective tissue; this corresponds to two cartilage elements per centimeter of tracheal length. Tracheal cartilages can calcify in elderly patients with a predilection for women and patients on longstanding warfarin therapy. The posterior (membranous) tracheal wall is devoid of cartilage and consists of longitudinally aligned smooth muscle, called trachealis muscle and fibrous connective tissue. The tracheal wall has a thickness of 1 to 3 mm and is delineated by intraluminal gas and mediastinal fatty tissue, as determined on CT scans.

The normal transverse internal diameter of the trachea ranges between 15 and 25 mm in men and 10 to 21 mm in women, with a cross-sectional area of 250 to 350 mm2 and a volume of 30 to 40 cm3 at total lung capacity (TLC) [1,3]. The transverse diameter of the trachea increases by 10 percent with inspiration and can decrease by 30 percent with coughing. During expiration, CT images display physiologic anterior bowing of the posterior non-carilaginous aspect of the posterior, membranous wall of the intrathoracic trachea while the anterolateral tracheal wall remains unchanged in its configuration.

The radiographic appearance of the tracheal air column should be assessed routinely when chest radiographs are obtained. If an endotracheal tube is present, proper position must be confirmed (figure 1). Aspiration of sand or other particulates may create a radiopaque outline of the trachea and large airways (image 2). Three-dimensional CT imaging and perspective rendering or virtual bronchoscopy are useful additional imaging tools [4].

                   

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Literature review current through: Jun 2015. | This topic last updated: May 28, 2015.
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References
Top
  1. Breatnach E, Abbott GC, Fraser RG. Dimensions of the normal human trachea. AJR Am J Roentgenol 1984; 142:903.
  2. Holbert JM, Strollo DC. Imaging of the normal trachea. J Thorac Imaging 1995; 10:171.
  3. Muller NL. Disease of the airways. In: Radiologic diagnosis of diseases of the chest, Muller, Fraser, Coleman, Pare (Eds), WP Saunders, Philadelphia 2001. p.452.
  4. Koletsis EN, Kalogeropoulou C, Prodromaki E, et al. Tumoral and non-tumoral trachea stenoses: evaluation with three-dimensional CT and virtual bronchoscopy. J Cardiothorac Surg 2007; 2:18.
  5. Altman RP, Randolph JG, Shearin RB. Tracheal agenesis: recognition and management. J Pediatr Surg 1972; 7:112.
  6. Saleeby MG, Vustar M, Algren J. Tracheal agenesis: a rare disease with unique airway considerations. Anesth Analg 2003; 97:50.
  7. Greiner A, Perkmann R, Rieger M, et al. Vascular ring causing tracheal compression in an adult patient. Ann Thorac Surg 2003; 75:1959.
  8. Zylak CJ, Eyler WR, Spizarny DL, Stone CH. Developmental lung anomalies in the adult: radiologic-pathologic correlation. Radiographics 2002; 22 Spec No:S25.
  9. Berdon WE, Baker DH, Wung JT, et al. Complete cartilage-ring tracheal stenosis associated with anomalous left pulmonary artery: the ring-sling complex. Radiology 1984; 152:57.
  10. Boiselle PM, Ernst A. State-of-the-art imaging of the central airways. Respiration 2003; 70:383.
  11. Goo JM, Im JG, Ahn JM, et al. Right paratracheal air cysts in the thoracic inlet: clinical and radiologic significance. AJR Am J Roentgenol 1999; 173:65.
  12. Caversaccio MD, Becker M, Zbären P. Tracheal diverticulum presenting with recurrent laryngeal nerve paralysis. Ann Otol Rhinol Laryngol 1998; 107:362.
  13. Soto-Hurtado EJ, Peñuela-Ruíz L, Rivera-Sánchez I, Torres-Jiménez J. Tracheal diverticulum: a review of the literature. Lung 2006; 184:303.
  14. Frenkiel S, Assimes IK, Rosales JK. Congenital tracheal diverticulum. A case report. Ann Otol Rhinol Laryngol 1980; 89:406.
  15. Moncada RM, Venta LA, Venta ER, et al. Tracheal and bronchial cartilaginous rings: warfarin sodium-induced calcification. Radiology 1992; 184:437.
  16. Ozdemir N, Ersu R, Akalin F, et al. Tracheobronchial calcification associated with Keutel syndrome. Turk J Pediatr 2006; 48:357.
  17. Latta RJ, Graham CB, Aase J, et al. Larsen's syndrome: a skeletal dysplasia with multiple joint dislocations and unusual facies. J Pediatr 1971; 78:291.
  18. Wolpoe ME, Braverman N, Lin SY. Severe tracheobronchial stenosis in the X-linked recessive form of chondrodysplasia punctata. Arch Otolaryngol Head Neck Surg 2004; 130:1423.
  19. Doolittle AM, Mair EA. Tracheal bronchus: classification, endoscopic analysis, and airway management. Otolaryngol Head Neck Surg 2002; 126:240.
  20. Siegel MJ, Shackelford GD, Francis RS, McAlister WH. Tracheal bronchus. Radiology 1979; 130:353.
  21. HARRIS JH Jr. The clinical significance of the tracheal bronchus. Am J Roentgenol Radium Ther Nucl Med 1958; 79:228.
  22. Barat M, Konrad HR. Tracheal bronchus. Am J Otolaryngol 1987; 8:118.
  23. Setty SP, Michaels AJ. Tracheal bronchus: case presentation, literature review, and discussion. J Trauma 2000; 49:943.
  24. Ghaye B, Szapiro D, Fanchamps JM, Dondelinger RF. Congenital bronchial abnormalities revisited. Radiographics 2001; 21:105.
  25. Wanderer AA, Ellis EF, Goltz RW, Cotton EK. Tracheobronchiomegaly and acquired cutis laxa in a child. Physiologic and immunologic studies. Pediatrics 1969; 44:709.
  26. Mounier-Kuhn, P. Dilatation de la Trachee: Constatations Radiographiques et Bronchoscopiques. Lyon Med 1932; 150:106.
  27. Shin MS, Jackson RM, Ho KJ. Tracheobronchomegaly (Mounier-Kuhn syndrome): CT diagnosis. AJR Am J Roentgenol 1988; 150:777.
  28. Hubbard M, Masters IB, Chang AB. Rapidly progressing case of Mounier-Kuhn Syndrome in early childhood. Pediatr Pulmonol 2003; 36:353.
  29. Rapti A, Drossos C, Tzavelas D, et al. Mounier-Kuhn syndrome (tracheobronchomegaly). Monaldi Arch Chest Dis 1995; 50:195.
  30. Woodring JH, Howard RS 2nd, Rehm SR. Congenital tracheobronchomegaly (Mounier-Kuhn syndrome): a report of 10 cases and review of the literature. J Thorac Imaging 1991; 6:1.
  31. Woodring JH, Barrett PA, Rehm SR, Nurenberg P. Acquired tracheomegaly in adults as a complication of diffuse pulmonary fibrosis. AJR Am J Roentgenol 1989; 152:743.
  32. Grillo HC. Surgical treatment of postintubation tracheal injuries. J Thorac Cardiovasc Surg 1979; 78:860.
  33. Ravin CE, Handel DB, Kariman K. Persistent endotracheal tube cuff overdistension: a sign of tracheomalacia. AJR Am J Roentgenol 1981; 137:408.
  34. Yamamoto AK, Babar JL. Case 184: ulcerative tracheobronchitis. Radiology 2012; 264:609.
  35. Gamsu G, Webb WR. Computed tomography of the trachea: normal and abnormal. AJR Am J Roentgenol 1982; 139:321.
  36. Kwong JS, Müller NL, Miller RR. Diseases of the trachea and main-stem bronchi: correlation of CT with pathologic findings. Radiographics 1992; 12:645.
  37. Chung JH, Kanne JP, Gilman MD. CT of diffuse tracheal diseases. AJR Am J Roentgenol 2011; 196:W240.
  38. Greene R, Lechner GL. "Saber-Sheath" Trachea: A Clinical and Functional Study of Marked Coronal Narrowing of the Intrathoracic Trachea. Radiology 1975; 115:265.
  39. Greene R. "Saber-sheath" trachea: relation to chronic obstructive pulmonary disease. AJR Am J Roentgenol 1978; 130:441.
  40. Bravo SM, Stark P, Jacobson F. Tracheobronchial cartilage calcifications in an inpatient population. J Thorac Imaging 1995; 10:220.
  41. Stark P, Norbash A. Imaging of the trachea and upper airways in patients with chronic obstructive airway disease. Radiol Clin North Am 1998; 36:91.
  42. MDCT evaluation of Nonneoplastic Tracheobronchial Stenoses. Contemporary Diagnostic Radiology 2008; 31:1.
  43. Stern EJ, Graham CM, Webb WR, Gamsu G. Normal trachea during forced expiration: dynamic CT measurements. Radiology 1993; 187:27.
  44. Boiselle PM. Imaging of the large airways. Clin Chest Med 2008; 29:181.
  45. Boiselle PM, Ernst A. Tracheal morphology in patients with tracheomalacia: prevalence of inspiratory lunate and expiratory "frown" shapes. J Thorac Imaging 2006; 21:190.
  46. Baroni RH, Feller-Kopman D, Nishino M, et al. Tracheobronchomalacia: comparison between end-expiratory and dynamic expiratory CT for evaluation of central airway collapse. Radiology 2005; 235:635.
  47. Zhang J, Hasegawa I, Hatabu H, et al. Frequency and severity of air trapping at dynamic expiratory CT in patients with tracheobronchomalacia. AJR Am J Roentgenol 2004; 182:81.
  48. Prince JS, Duhamel DR, Levin DL, et al. Nonneoplastic lesions of the tracheobronchial wall: radiologic findings with bronchoscopic correlation. Radiographics 2002; 22 Spec No:S215.
  49. Choplin RH, Wehunt WD, Theros EG. Diffuse lesions of the trachea. Semin Roentgenol 1983; 18:38.
  50. Restrepo S, Pandit M, Villamil MA, et al. Tracheobronchopathia osteochondroplastica: helical CT findings in 4 cases. J Thorac Imaging 2004; 19:112.
  51. Hantous-Zannad S, Sebaï L, Zidi A, et al. Tracheobronchopathia osteochondroplastica presenting as a respiratory insufficiency: diagnosis by bronchoscopy and MRI. Eur J Radiol 2003; 45:113.
  52. Zack JR, Rozenshtein A. Tracheobronchopathia osteochondroplastica: report of three cases. J Comput Assist Tomogr 2002; 26:33.
  53. Karlikaya C, Yüksel M, Kiliçli S, Candan L. Tracheobronchopathia osteochondroplastica. Respirology 2000; 5:377.
  54. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 32-1999. A 44-year-old man with tracheal narrowing and respiratory stridor. N Engl J Med 1999; 341:1292.
  55. Nienhuis DM, Prakash UB, Edell ES. Tracheobronchopathia osteochondroplastica. Ann Otol Rhinol Laryngol 1990; 99:689.
  56. Grillo HC, Wright CD. Airway obstruction owing to tracheopathia osteoplastica: treatment by linear tracheoplasty. Ann Thorac Surg 2005; 79:1676.
  57. Soni NK. Scleroma of the larynx. J Laryngol Otol 1997; 111:438.
  58. Allen SD, Harvey CJ. Imaging of Wegener's granulomatosis. Br J Radiol 2007; 80:757.
  59. Verma A, Park HY, Lim SY, et al. Posttuberculosis tracheobronchial stenosis: use of CT to optimize the time of silicone stent removal. Radiology 2012; 263:562.
  60. Buckley JA, Stark P. Intrathoracic mediastinal thyroid goiter: imaging manifestations. AJR Am J Roentgenol 1999; 173:471.
  61. Ahuja J, Kanne JP, Meyer CA, et al. Histiocytic disorders of the chest: imaging findings. Radiographics 2015; 35:357.
  62. Karlins NL, Yagan R. Dyspnea and hoarseness. A complication of diffuse idiopathic skeletal hyperostosis. Spine (Phila Pa 1976) 1991; 16:235.
  63. Grillo HC, Mathisen DJ. Primary tracheal tumors: treatment and results. Ann Thorac Surg 1990; 49:69.
  64. Park CM, Goo JM, Lee HJ, et al. Tumors in the tracheobronchial tree: CT and FDG PET features. Radiographics 2009; 29:55.
  65. Kim TS, Lee KS, Han J, et al. Mucoepidermoid carcinoma of the tracheobronchial tree: radiographic and CT findings in 12 patients. Radiology 1999; 212:643.
  66. Weber AL, Grillo HC. Tracheal tumors. A radiological, clinical, and pathological evaluation of 84 cases. Radiol Clin North Am 1978; 16:227.
  67. Hazama K, Miyoshi S, Akashi A, et al. Clinicopathological investigation of 20 cases of primary tracheal cancer. Eur J Cardiothorac Surg 2003; 23:1.
  68. Gaissert HA. Primary tracheal tumors. Chest Surg Clin N Am 2003; 13:247.
  69. Schneider P, Schirren J, Muley T, Vogt-Moykopf I. Primary tracheal tumors: experience with 14 resected patients. Eur J Cardiothorac Surg 2001; 20:12.
  70. Regnard JF, Fourquier P, Levasseur P. Results and prognostic factors in resections of primary tracheal tumors: a multicenter retrospective study. The French Society of Cardiovascular Surgery. J Thorac Cardiovasc Surg 1996; 111:808.
  71. Dean CW, Speckman JM, Russo JJ. AIRP best cases in radiologic-pathologic correlation: adenoid cystic carcinoma of the trachea. Radiographics 2011; 31:1443.
  72. Kwak SH, Lee KS, Chung MJ, et al. Adenoid cystic carcinoma of the airways: helical CT and histopathologic correlation. AJR Am J Roentgenol 2004; 183:277.
  73. Kim TS, Lee KS, Han J, et al. Sialadenoid tumors of the respiratory tract: radiologic-pathologic correlation. AJR Am J Roentgenol 2001; 177:1145.
  74. Li X, Zhang W, Wu X, et al. Mucoepidermoid carcinoma of the lung: common findings and unusual appearances on CT. Clin Imaging 2012; 36:8.
  75. Fisher DA, Mond DJ, Fuchs A, Khan A. Mucoepidermoid tumor of the lung: CT appearance. Comput Med Imaging Graph 1995; 19:339.
  76. Aribas OK, Kanat F, Avunduk MC. Pleomorphic adenoma of the trachea mimicking bronchial asthma: report of a case. Surg Today 2007; 37:493.
  77. Briselli M, Mark GJ, Grillo HC. Tracheal carcinoids. Cancer 1978; 42:2870.
  78. Marom EM, Goodman PC, McAdams HP. Focal abnormalities of the trachea and main bronchi. AJR Am J Roentgenol 2001; 176:707.
  79. Barker AP, Carter MJ, Matz LR, Armstrong JA. Plasma-cell granuloma of the trachea. Med J Aust 1987; 146:443.
  80. Sandstrom RE, Proppe KH, Trelstad RL. Fibrous histiocytoma of the trachea. Am J Clin Pathol 1978; 70:429.
  81. McCarthy MJ, Rosado-de-Christenson ML. Tumors of the trachea. J Thorac Imaging 1995; 10:180.
  82. Lam CW, Talbot AR, Yeh KT, et al. Human papillomavirus and squamous cell carcinoma in a solitary tracheal papilloma. Ann Thorac Surg 2004; 77:2201.
  83. Harris K, Chalhoub M. Tracheal papillomatosis: what do we know so far? Chron Respir Dis 2011; 8:233.
  84. Siegel MJ, McAlister WH. Tracheal histiocytoma: an inflammatory pseudotumor. J Can Assoc Radiol 1978; 29:273.
  85. Stark P. Imaging of tracheobronchial injuries. J Thorac Imaging 1995; 10:206.
  86. Wain JC. Postintubation tracheal stenosis. Chest Surg Clin N Am 2003; 13:231.
  87. Zias N, Chroneou A, Tabba MK, et al. Post tracheostomy and post intubation tracheal stenosis: report of 31 cases and review of the literature. BMC Pulm Med 2008; 8:18.
  88. Kligerman S, Sharma A. Radiologic evaluation of the trachea. Semin Thorac Cardiovasc Surg 2009; 21:246.
  89. Weber AL, Grillo HC. Tracheal stenosis: an analysis of 151 cases. Radiol Clin North Am 1978; 16:291.
  90. Gunn ML, Clark RT, Sadro CT, et al. Current concepts in imaging evaluation of penetrating transmediastinal injury. Radiographics 2014; 34:1824.
  91. Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med 1981; 70:65.
  92. Carbognani P, Bobbio A, Cattelani L, et al. Management of postintubation membranous tracheal rupture. Ann Thorac Surg 2004; 77:406.
  93. Godoy MC, Saldana DA, Rao PP, et al. Multidetector CT evaluation of airway stents: what the radiologist should know. Radiographics 2014; 34:1793.
Topic Outline

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