Tears of the trachea and main bronchi caused by blunt trauma: radiologic findings

Although most of the radiologic changes that have been described in transection or laceration of the trachea or main bronchi are nonspecific, they can be of diagnostic importance in the appropriate clinical setting. In order to reassess the significance of these findings, and to determine the presence of any other changes that might lead to a definitive diagnosis, we retrospectively reviewed the chest radiographs of nine patients who had tears or transection of the trachea and/or main bronchi as a result of blunt chest trauma. The diagnosis was proved by bronchoscopy in all patients and reconfirmed at surgery in five. The predominant findings on the chest radiographs were related to air leak and included subcutaneous emphysema (seven patients), pneumomediastinum (seven patients), pneumothorax (six patients), and air surrounding a bronchus in one patient. Upper thoracic fractures that involved the clavicles, scapula, sternum, and ribs were present in four patients. Abnormalities in the appearance of an endotracheal tube in two patients (overdistention of the cuff or extraluminal position of the tip), and the presence of the fallen lung sign (collapse of the lung toward the lateral chest wall) in two others provided specific evidence of tracheobronchial injury. We conclude that, although the major importance of the chest radiograph in patients with tracheobronchial transection may be to verify the existence of air leak, the presence of the fallen lung sign and endotracheal tube abnormalities is a reliable indication of airway injury.     

Tracheal and main bronchial diverticula: the role of CT

PURPOSE: This paper describes an asymptomatic and rarely diagnosed entity without a clear correlation with respiratory disease identified in 1%-2% of cases at spiral computed tomography (CT). MATERIALS AND METHODS: We retrospectively reviewed the CT features of air collections contiguous to the tracheal or main bronchial wall and communicating with the airway in 16 patients undergoing CT for other reasons. Four patients were also studied by virtual bronchoscopy and three by actual bronchoscopy. RESULTS: Thirteen of the 16 patients had a single diverticulum, whereas the remaining three had multiple diverticula. Only one patient had a bronchial diverticulum. The most frequent site was the right posterolateral wall of the trachea at the level of the second or third thoracic vertebral body. In 2/3 of patients, chronic obstructive pulmonary disease was not documented. CONCLUSIONS: CT was the most effective method for evaluating the presence and features of diverticula. A correlation between tracheobronchial diverticula and chronic respiratory disease was documented in 5/16 patients, whereas no respiratory disorder was identified in the remaining 11. Although chronic inflammatory tracheobronchial changes and increased endoluminal pressure may be important causes, we hypothesise that other, as yet unknown, aetiopathological factors could exist.     

原发性气管支气管淀粉样变的MSCT诊断

目的：探讨原发性气管支气管淀粉样变的 MSCT 表现。方法：搜集本院经病理证实的5例原发性气管支气管淀粉样变性的影像资料，对病变气管支气管壁厚度、密度、管腔形态及病变范围进行回顾性分析。结果：弥漫型4例，受累气管支气管壁环形增厚，呈连续性分布，管壁厚度3～6mm，其中气管至3级支气管2例，气管至4级支气管2例。2例气道壁呈片状及环状钙化，以支气管明显，2例为局灶性小钙化。局限型1例，表现为右侧中间段支气管管壁增厚，管腔狭窄，气道壁未见明显钙化，患侧肺门淋巴结肿大并伴有蛋壳样钙化。气道内膜凹凸不平4例，1例尚光滑。5例管腔均出现不同程度狭窄，1例2级支气管闭塞伴肺不张，1例气管至2级支气管狭窄，3～5级支气管管腔相对扩大，继发感染。结论：原发性气管支气管淀粉样变性 MSCT 主要表现为气道壁结节样增厚，局灶性或弥漫性分布，伴或不伴有钙化，气管壁后部可以受累。     

Blunt nonaortic chest trauma: radiographic and CT findings

Following initial clinical evaluation and stabilization of a patient who has sustained blunt chest trauma, imaging has an important role in the evaluation of thoracic injuries. The initial study is the chest radiograph. However, chest CT is being used with increased frequency in the evaluation of blunt chest trauma. Although CT is used primarily to assess for traumatic aortic injuries, it is also useful in the evaluation of pulmonary and bronchial, airway, skeletal and diaphragmatic injury. The aim of this article is to review the characteristic imaging findings of pulmonary and bronchial, esophageal, thoracic, skeletal and diaphragmatic injuries. Electronic Publication     

Esophageal injuries: spectrum of multidetector row CT findings

BACKGROUND: Aim of this study is to illustrate the multidetector row computed tomographic findings related to oesophageal injuries and their significance for therapeutic decisions. METHOD: From April 2002 to April 2005 we studied 16 patients with suspected oesophageal injury. Ten patients underwent standard chest radiograph, while five patients with suspected foreign body ingestion were submitted to cervical plain film and gastrografin swallow study. All 16 patients underwent multidetector row CT examination. RESULTS: In six patients with cervical, thoracic and abdominal trauma, CT showed the presence of thoracic traumatic lesions and findings suggestive of perforation of the oesophagus. In five patients with foreign body ingestion cervical radiography was positive in only one case, while CT showed the presence of a foreign body in all cases. In three patients with post-intubation complications, CT showed the presence of perioesophageal fluid collection containing small gas bubbles in two cases and an oesophageal-aortic fistula in one case. In the remaining two patients with suspected spontaneous oesophageal perforation, CT demonstrated an oesophageal wall oedema and thickening in one case, and oesophageal fluid distension with perioesophageal small bubbles gas and fluid in the second case. CONCLUSION: Oesophageal injuries, when complicated with perforation, constitute a life-threatening condition. Knowledge of the CT signs of oesophageal injuries has important implications for the role of imaging at the time of initial diagnosis.     

An unusual case of bronchial rupture—pneumomediastinum appearing 7 days after blunt chest trauma

We present a case of bronchial disruption after blunt chest trauma, which is unusual because the pneumomediastinum on the chest radiograph was detected 7 days after the injury. The first day imaging methods of the thorax showed only the fractures of the first and third left rib without any complications. A computed tomography (CT) scan was done following control chest radiograph and it revealed a rupture of the left main bronchus with pleural effusion, subcutaneous emphysema and pneumomediastinum. This case shows that a finding of pneumomediastinum after blunt chest trauma should always merit further investigation of its cause, even in cases of postponed detection of pneumomediastinum and regardless of the absence of other indicators of tracheobronchial disruption. Although fiber-optic tracheobronchoscopy is considered a diagnostic golden standard, in this case, diagnosis was clearly confirmed by spiral CT scan, due to thin slices and continuous data acquisition.     

多层螺旋CT仿真支气管镜对气管支气管病变的诊断价值

目的评价多层螺旋CT仿真支气管镜（CTVB）对气管、支气管病变的诊断价值。方法对42例患者进行多层螺旋CT检查，在工作站得到仿真支气管图像，采用螺距1．35，重组间隔1mm，重组层厚1．25mm。其中35例为中央型肺癌、3例支气管内膜结核、3例支气管良性肿瘤经病理证实，1例支气管异物经临床证实。所有图像均经2名熟悉气管支气管解剖的放射科医师进行分析。结果42例中，35例中央型肺癌CTVB表现为气管支气管腔内结节状或丘状隆起者22例，狭窄13例，以上35例中央型肺癌横断面CT均显示病变部位支气管壁呈不同程度增厚。3例支气管内膜结核CTVB均表现为支气管腔狭窄，横断面CT显示管壁增厚，管壁增厚范围长。3例气管支气管良性肿瘤CTVB表现为腔内结节，横断面CT无相邻支气管壁的增厚。另1例支气管腔内异物CTVB表现为支气管腔内隆起性阻塞，横断面CT无相邻支气管壁的增厚。CTVB可以越过狭窄部位对远端支气管进行观察。结论多层螺旋CTVB可以反映气管支气管腔内病变的形态，结合横断面CT对气管支气管病变的诊断具有参考价值。     

淋巴管肌瘤病的影像表现

目的：探讨淋巴管肌瘤病(LAM)的影像学诊断价值。方法 回顾性分析15例经临床和病理证实的LAM胸部X线平片、HRCT,腹部CT和直接淋巴管造影(DLG)及DLG后胸腹部CT扫描等影像资料。结果 15例中,X线胸片上未见异常1例,双肺纹理增多3例,弥漫性小蜂窝状影或网格状影11例,气胸2例,胸腔积液14例。胸部常规CT和HRCT扫描显示15例均具有典型LAM表现,均可见两肺散在囊状影或广泛密布的囊状影。按Avila等肺部疾病程度分级标准：Ⅰ级3例;Ⅱ级5例;Ⅲ级7例。腹部CT显示14例在腹膜后、盆腔可见囊性淋巴管瘤9例,淋巴管肌瘤13例,二者共同存在7例,并发肝脏脂肪瘤和血管平滑肌脂肪瘤、肾脏小错构瘤及子宫肌瘤各1例。DLG检查,除1例淋巴管梗阻部位在腰3水平外,其余14例均可见胸导管不同程度的狭窄、梗阻及颈干和（或）锁骨下干和（或）支气管纵隔干淋巴管反流。DLG术后CT,除3例未显示胸导管出口梗阻外,其余12例显示胸导管出口梗阻情况与DLG基本一致。结论 HRCT对肺淋巴管肌瘤(PLAM)的诊断具有特征性价值,CT可发现腹部LAM,DLG和DLG后MSCT对因LAM引起的胸导管或淋巴管干梗阻部位的显示具有价值,可为手术治疗提供一定的帮助。     

Tracheobronchial amyloidosis: A case report and review of literature

Tracheobronchial amyloidosis, manifested by amyloid deposits limited specifically to tracheal and bronchial tissue, is a rare manifestation with only a few hundred published cases. Patients classically present with symptoms related to fixed upper airway obstruction caused by tracheal stenosis. Clinical symptoms are non-specific and include hoarseness, dyspnea, cough, stridor, hemoptysis, and dysphagia, which are similar to those caused by more common airway disorders, often leading to incorrect, missed, and delayed diagnosis. The wide-spread use of computerized tomography (CT) imaging has the potential of dramatically advancing the early diagnosis of tracheobronchial amyloidosis. We present a case of a patient with chronic and progressive hoarseness, diagnosed with tracheobronchial amyloidosis, with a focus on unusually clear and precise CT soft tissue neck imaging. CT imaging demonstrated nodular circumferential raised mass-like thickening involving the long-segment posterior wall of the distal trachea. The wall thickening also extended into the proximal left main stem bronchi, but spared the distal bronchial tree. This resulted in moderate (approximately 50%) narrowing of the tracheal lumen, which explained the patient''s hoarseness. Routine CT imaging of patients with chronic and progressive respiratory symptoms, including cough, hoarseness, and dyspnea, is recommended. Tracheobronchial amyloidosis is an uncommon disease, but it may become more commonly recognized with broader use of more effective CT imaging protocols.     

The spherical endotracheal tube cuff: A plain radiographic sign of tracheal injury

Tracheobronchial injury is an uncommon event associated with blunt chest trauma. The clinical signs and symptoms as well as plain radiographic findings are usually nonspecific, so a high index of suspicion is required for early detection and optimal management. This report describes a severely traumatized patient whose tracheal inury was suspected when a spherical endotracheal tube cuff was noted on a portable trauma chest radiograph.     

Imaging of chest trauma: radiological patterns of injury and diagnostic algorithms

In patients after chest trauma, imaging plays a key role for both, the primary diagnostic work-up, and the secondary assessment of potential treatment. Despite its well-known limitations, the anteroposterior chest radiograph remains the starting point of the imaging work-up. Adjunctive imaging with computed tomography, that recently is increasingly often performed on multidetector computed tomography units, adds essential information not readily available on the conventional radiograph. This allows better definition of trauma-associated thoracic injuries not only in acute traumatic aortic injury, but also in pulmonary, tracheobronchial, cardiac, diaphragmal, and thoracic skeletal injuries. This article reviews common radiographic findings in patients after chest trauma, shows typical imaging features resulting from thoracic injury, presents imaging algorithms, and recalls to the reader less common but clinically relevant entities encountered in patients after thoracic trauma.     

Using CT to diagnose tracheal rupture

OBJECTIVE: A retrospective study was performed to assess CT sensitivity for diagnosing tracheal rupture. Intubated cadaver tracheas were examined to assess endotracheal tube balloon overdistention and deformity and to evaluate the relationship of balloon pressures to tracheal injury. MATERIALS AND METHODS: Neck or chest CT scans of 14 patients with tracheal rupture and 41 control trauma patients with pneumomediastinum but without tracheal injury were reviewed and compared to assess the presence and location of extrapulmonary air, whether direct visualization of tracheal wall disruption was possible, the size and shape of endotracheal tube balloon, signs of transtracheal balloon herniation in intubated patients, and the location of the extratracheal endotracheal tube. Intact and experimentally injured cadaver tracheas were used to evaluate tube balloon pressure and configuration. RESULTS: All 14 patients with tracheal rupture had deep cervical air and pneumomediastinum. Overdistention of the tube balloon occurred in 71% (5/7) of the intubated patients, and balloon herniation occurred in 29% (2/7). Direct tracheal injury was seen in 71% (10/14) of the patients as a wall defect (n = 8) or deformity (n = 2). Overall, CT was 85% sensitive for detecting tracheal injury. Patients with tracheal injury had a significantly lower incidence of pneumothorax (p = 0.01) than did the control group. The CT appearance of balloon herniation through defects in the cadaver tracheas closely mimicked those of patients with tracheal injury. The amount of balloon pressure required to rupture the intubated trachea was extremely high and rupture was difficult to obtain. CONCLUSION: CT can reveal tracheal injury and can be used to select trauma patients with pneumomediastinum for bronchoscopy, leading to early confirmation and treatment.     

金属支架治疗大气道狭窄

目的　探讨气管支架成形术缓解大气道狭窄的方法、安全性和疗效。资料与方法　气管狭窄患者 32例 ,其中气管切开或插管后局部组织过度增生 7例 ,转移性肿瘤压迫气管 12例 ,多发性软骨炎引起气管塌陷 1例 ,肺癌 12例 ;单纯气管狭窄 2 8例 ,主支气管狭窄 1例 ,气管支气管同时有狭窄者 3例。术前均经CT检查及气管体层片证实气管、支气管狭窄。 13例术前用的卡因喷喉麻醉 ,19例在全身麻醉下置入支架。结果　 32例共放置 37枚气管支架 ,均一次置入成功 ,无操作失败 ,通气全部得到改善 ,手术成功率 10 0 %。 2例气管狭窄经置入支架后复发狭窄再次置入支架。 33枚置于气管 ,4枚置于主支气管。 1例狭窄严重仅容 4F导管通过 ,用球囊导管扩张至 12mm后置入支架 ;其余均直接置入支架。术后通气功能明显改善 ,无需吸氧 ,无明显胸痛、咯血等并发症。 1周后X线复查无支架移位 ,可见支架进一步扩张。 1例甲状腺癌支架置入术后 2周复发呼吸困难 ,CT扫描示支架内有新生物 ,经支架内放射治疗后症状消失。结论　气管内支架成形术方法简单、安全 ,缓解呼吸困难疗效迅速、确实 ,适合良恶性气道狭窄姑息治疗     

气管支气管树涎腺样肿瘤的影像表现

目的：探讨气管支气管树涎腺样肿瘤的影像表现，以提高诊断正确率。方法：回顾性分析经组织学证实的腺样囊性癌（ACC）62例，其中有术前影像资料者40例，包括传统X线检查33例，CT扫描21例（增强扫描11例），黏液表皮样癌（MEC）27例，有术前影像资料者18例，包括传统X线检查17例，CT扫描6例（增强扫描5例）。结果：（1）病变部位：ACC：中央型37例，以原发气管最多（26例）,周围型3例，MEC：中央型13例，以叶支气管起源为主（8例），周围型5例。除1例ACC外，周围型病变均位于肺中野内带，邻近肺门。（2）CT表现：ACC：18例中央型病变中腔内型3例，腔内外型14例（伴管壁浸润状增厚8例），单纯管壁浸润状增厚型1例，平扫密度均低于或近，等于肌肉，11例增强后密度仍低于或近，等于肌肉者8例，病变边缘呈浸润状，提示外侵8例，MEC：6例中央型病变中腔内型5例，腔内外型1例，无一例有管壁浸润状增厚；增强后病变明显强化高于肌肉4例；瘤内点状钙化3例，病变远端见低密度黏液栓1例；病变边缘清楚，未见明确局部侵犯。结论：气管支气管树涎腺样肿瘤好发于大气道；ACC多见于气管，MEC多见于气管分叉下大气道，两者均可表现为腔内型，腔内外型及近肺门的周围型肿物。ACC以腔内外型为主，并常用现管壁浸润状增厚，与肿瘤局部侵袭性生长有关，病变密度低，增强后强化不明显，MEC以腔内型为主，无管壁浸润状增厚，增强后明显强化，约半数病变内可见钙化，病变远端可有支气管扩张及黏液栓形成。     

18例创伤性气管、支气管断裂的诊断与治疗

目的　探讨创伤性气管、支气管断裂的诊断和治疗方法 ,提高诊断率及治疗效果。方法　回顾性分析 18例创伤性气管、主支气管断裂病人的临床资料。 15例行支气管端端吻合术 ,1例行支气管修补术 ,其中 1例术后支气管狭窄而行肺叶切除术 ,1例行气管修补术 ,1例行狭窄气管切除、气管端端吻合、T形硅胶管置管术。术后行纤维支气管镜 (FB)检查。结果　术后早期吻合口水肿狭窄呈裂隙状 2例 ,1个月后复查局部通畅均为良好。结论　创伤性支气管断裂容易误诊 ,FB检查是早期诊断最重要的手段 ,后期在切除狭窄段支气管时瘢痕要切除干净     

Radiographic detection of esophageal malpositioning of endotracheal tubes

Insertion of an endotracheal tube into the esophagus is an infrequent but life-threatening complication of endotracheal intubation. This complication is difficult to detect on standard, anteroposterior, portable chest radiographs because the incorrectly placed endotracheal tube is usually projected over the tracheal air column. To evaluate the use of chest radiographs to detect the malposition, we performed a two-part study. First, we analyzed the findings on chest radiographs in six patients in whom an endotracheal tube had been inserted in the esophagus, and then we analyzed 328 portable chest radiographs of patients with both endotracheal and nasogastric tubes to determine the best radiographic position for identifying the exact location of an endotracheal tube. The findings in the six patients included projection of the tube lateral to the trachea (five patients), gastric distension (four patients), esophageal air (two patients), and deviation of the trachea by the balloon cuff (one patient). The study of the portable chest radiographs showed that the endotracheal tube position could be identified correctly in 81 (92%) of 88 of the films made with the patient in a 25 degrees right posterior oblique position. The trachea and esophagus were superimposed in 25 (96%) of 26 of the radiographs made with the head turned to the left and with the patient in a 25 degrees left posterior oblique projection. Our results show that by positioning patients for chest radiographs in a 25 degrees right posterior oblique position, the location of endotracheal tubes can be identified accurately.     

Early radiographic signs of tracheal rupture

Early diagnosis and repair of tracheal rupture are necessary to prevent acute tension pneumothorax, airway obstruction, and chronic tracheal stenosis. Few reliable radiographic signs of tracheal rupture have been proposed. We diagnosed seven cases of tracheal rupture, two related to blunt trauma and five resulting from tracheal intubation. Early radiographic signs included orientation of the distal portion of the endotracheal tube to the right relative to the lumen of the trachea with an overdistended endotracheal balloon cuff, migration of the balloon toward the endotracheal tube tip, and pneumomediastinum and subcutaneous emphysema. In four cases, the overdistended balloon with distal migration preceded the pneumomediastinum by several hours. An overdistended balloon in a patient after tracheal intubation or blunt chest trauma should suggest tracheal rupture.     

骨化性气管支气管病的CT诊断

目的 探讨骨化性气管支气管病的CT特征，提高对该病的认识。方法 回顾分析6例经病理证实的骨化性气管支气管病的CT表现。结果 CT主要表现为气管、主支气管前壁和侧壁黏膜下散在或多发的斑块状小结节突起，突向管腔，部分结节钙化，大多数小结节直径在2～4mm，有2例在叶支气管可见；2例同时出现气管壁增厚，气管环变形，管腔狭窄。结论 气管、主支气管内多发的黏膜下小结节钙化影并突向管腔是骨化性气管支气管病较具特征性的CT表现。     

螺旋CT测量日本大耳白兔气道径线的窗宽窗位选择

目的探讨日本大耳白兔气管和主支气管解剖径线CT测量的窗位与窗宽选择,为气道支架动物实验奠定基础。方法多层螺旋CT扫描30只成年健康日本大耳白兔的胸部,分别常规肺窗、纵隔窗和特殊的脂肪窗测量气管胸段前后径、左右径、左右主支气管前后径。比较不同窗宽窗位下气管壁显示以及测量数据与解剖数据之间的差异。结果肺窗气管壁均清晰显示,但测量的结果偏小;纵隔窗气管壁显示模糊,测量的结果偏大;而脂肪窗气管壁显示均匀,测量的数据比较接近实际气管直径的解剖参数。结论多层螺旋CT测定日本大耳白兔气管左右径和前后径应选择脂肪窗为佳。有助于为人相关气管和支气管定制气道支架确定最佳的窗宽和窗位。     

多层螺旋CT三维重建技术对气管支气管淀粉样变的诊断价值

目的：评价多层螺旋CT三维重建技术对气管支气管淀粉样变的临床诊断价值。方法回顾性分析7例经支气管纤维镜及临床、病理最终确诊为气管支气管淀粉样变的患者,对其进行多层螺旋CT扫描,所有数据均发送到工作站进行三维重建。结果7例病例中,男性4例,女性3例,年龄35~61岁,中位年龄47岁。CT横段位及三维重建技术显示：病变范围长,呈连续性,累及气管2例,累及主支气管4例,累及叶、段支气管达7例,管壁增厚钙化为主,管壁钙化以支气管明显,钙化主要表现为块状或长条状。气管及支气管管腔明显狭窄,所有病例均出现不同程度的管腔狭窄,继发肺部阻塞性炎症5例。结论多层螺旋CT三维重建技术可通过立体、多方位观察气管及支气管情况,明确气管支气管淀粉样变受累范围,了解管壁、管腔情况,可为临床及放射科医生提供更多可靠信息,对准确诊断该病起至关重要的帮助。