American Journal of Medicine, internal medicine, medicine, health, healthy lifestyles, cancer, heart disease, drugs

Polypoidal Trachea: A Clinician’s Predicament

Fiber-optic bronchoscopic image showing multiple submucosal nodules characteristically sparing posterior membranous (A). Narrow-band imaging not showing the intraepithelial capillary loop pattern with dark brown dots (B). Axial and coronal scan depicting calcifications within the tracheal lumen (C and D).

A 44-year-old asymptomatic female patient with no known comorbidities was scheduled for donor kidney harvesting for her husband. During intubation, the anesthetist found multiple polypoidal lesions just below the vocal cords, studding the tracheal wall. A diagnosis of multiple tracheal papillomatosis was made, and the patient was referred to the Otorhinolaryngology Department for further evaluation. Flexible bronchoscopic assessment revealed multiple submucosal calcified nodules distributed along the anterolateral tracheal wall, sparing the posterior membranous wall (Figure A). Further, narrow-band imaging (NBI) did not reveal any vascular pattern typical of papillomas (Figure B), excluding the possibility of tracheal viral papillomatosis. A prompt imaging diagnosis of tracheobronchopathia osteochondroplastica (TO) was made using NBI assistance. Endoscopic biopsy was performed, which demonstrated submucosal chondroid tissue as well as foci of ossification, confirming the clinical diagnosis. Contrast-enhanced computed tomography (CECT) of the chest was performed preoperatively to assess the airway lumen and to estimate the possible size of endotracheal tube to be used during intubation (Figure C and D). The anesthetist was made aware of the benign nature of the condition, and the patient underwent successful surgery without any intubation difficulty using a smaller size endotracheal tube (6.5 mm).

 

Discussion

TO, also known as tracheopathia osteoplastica, is a rare, benign airway disease of unknown etiology. TO is characterized by multiple cartilaginous or bony submucosal nodules, arising from the airway cartilage and projecting into the lumen, typically sparing the posterior membranous tracheal wall.1

The exact etiology of TO is still unknown. Because TO is characterized by inflammation surrounding osseocartilaginous deposits underneath the mucosa of the tracheobronchial tree, chronic infection was postulated as a possible etiologic factor.1, 2 However, these infections are likely the result of TO, rather than the cause of it.1

TO is usually diagnosed in the elderly in their sixth or seventh decade of life. In general, there is no gender predilection, although few studies have observed a male predominance.1 Because the pathological process is slow and progresses gradually over a long period of time, a majority of the affected individuals remain asymptomatic and are diagnosed incidentally either during bronchoscopy for other indications or secondary to difficult intubation.3

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-Pirabu Sakthivel, MSa, Kapil Sikka, MSa,Aanchal Kakkar, MDb, Sasikrishna Kavutharapu, MSa, Alok Thakar, MSa

-This article originally appeared in the March issue of The American Journal of Medicine.

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