THE TRACHEA

Presented by R3 Piyanuch
Advisor : Aj . Suwimon
 THE TRACHEA
WELCOME!
Location
- Inferior aspect of cricoid
cartilage to carina (C6-T5
level)
- Divided into intrathoracic
and extrathoracic part by the
manubrium
 THE TRACHEA
WELCOME!
Posterior tracheal
membrane
Trachealis
muscle

Tracheal wall
Hyaline
Cartilage - Mucosa
- Submucosa
Mucosa - Hyaline cartilage ring
- Trachealis muscle
Submucosa - Adventitia

Adventitia
 THE TRACHEA
WELCOME!
Posterior tracheal
membrane
Trachealis
muscle Hyaline cartilage

Hyaline - 16-22 C-shape cartilage

Cartilage at anterior and lateral
tracheal wall
Mucosa - except the posterior wall
which has thin trachealis
Submucosa muscle and posterior
tracheal membrane
Adventitia
 THE TRACHEA
WELCOME!
 THE TRACHEA
WELCOME!

Tracheal Coronal Sagittal

diameter
Male 13-25 mm 13-27 mm
The tracheal wall is outlined by mediastinal fat,
visible as 1-2 mm soft tissue stripe. Female 10-21 mm 10-23 mm
 THE TRACHEA
WELCOME!

Inspire Expire

Round shape Anterior bowing of posterior

tracheal membrane
 THE TRACHEA
WELCOME!

Normal calcification of
tracheal cartilage in elderly
 TRACHEAL
ABNORMALITY
 TRACHEAL ABNORMALITY

TRACHEAL NARROWING INCREASE DIAMETER

Tracheal Tumors Tracheal Diverticulum
Tracheomalacia Mounier-Kuhn Syndrome
Tuberculosis
Tracheal Stenosis
Saber-sheath Trachea
Wegener’s Granulomatosis
Amyloidosis
Sarcoidosis
Tracheobronchopathia
Osteochondroplastica
Relapsing Polychondritis
 TRACHEAL NARROWING

Focal Focal/Diffuse Diffuse

Tracheal Tumors Tracheomalacia Saber-sheath Trachea

Tuberculosis Wegener’s Granulomatosis Tracheobronchopathia
Tracheal Stenosis Amyloidosis Osteochondroplastica
Sarcoidosis Relapsing
Polychondritis
TRACHEAL
WELCOME! TUMOR
Malignant
Benign
Squamous cell papilloma
Papillomatosis
Primary Metastasis
Hamartoma
Other mesenchymal Squamous cell carcinoma Direct invasion
tumors Adenoid cystic carcinoma Hematogenous
Mucoepidermoid carcinoma spreading
Carcinoid tumor
Sarcoma
Lymphoma
TRACHEAL
WELCOME! TUMOR

Polypoid Circumferential wall thickening Sessile

TRACHEAL
WELCOME! TUMOR
Squamous cell carcinoma

1st most common primary tracheobronchial malignancy

M>F, 50-70 yrs
Associated smoking
Involve distal trachea, main bronchus
Focal or circumferential thickening polypoid mass with smooth,
lobular or irregular margin
1/3 Pts have LN or lung metastasis
 SCC arises from the surface epithelium,
TRACHEAL
WELCOME! TUMOR the tumor surface is typically irregular

Squamous cell carcinoma

An irregular well-defined nodule in the

distal trachea
TRACHEAL
WELCOME! TUMOR
Adenoid cystic carcinoma
2nd most common primary tracheobronchial
malignancy
M=F, 30-50 yrs, non-smokers
Involve upper trachea esp. posterolateral wall,
central airway
Focal smooth endoluminal polypoid mass or
smooth circumferential wall thickening
Submucosal spreading
Rare metastasis, often local recurrent
 Because of its submucosal origin, ACC
TRACHEAL
WELCOME! TUMOR tends to have an intact epithelium and
a smooth contour

Adenoid cystic carcinoma

Smooth sessile mass arise from posterior Circumferential wall thickening of the trachea
tracheal wall and protrude in tracheal lumen
TRACHEAL
WELCOME! TUMOR
Mucoepidermoid carcinoma
Rare tracheobronchial tumor
Originate from the minor salivary glands lining tracheobronchial tree
Involve lobar or segmental bronchus rather than trachea or main
bronchus
Oval or lobulated intraluminal mass with mild contrast enhancement,
punctate calcification within tumor
Frequently associated with postobstructive pneumonia or mucoid
impaction
Good prognosis
TRACHEAL
WELCOME! TUMOR
Mucoepidermoid carcinoma

A polypoid mass at distal trachea with internal calcification

TRACHEAL
WELCOME! TUMOR
Carcinoid tumor
Neuroendocrine neoplasm of
Tracheobronchial tree
Inv. the main lobar or segmental
bronchi (extremely rare in trachea)
A well-defined spherical or ovoid
nodule with a slightly lobulated
border
Intense contrast enhancement
Punctate or diffuse calcification
upto 30%
TRACHEAL
WELCOME! TUMOR
Carcinoid tumor

NC A. PC

A polypoid mass within left main bronchus with avid contrast enhancement
TRACHEAL
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Metastasis

Direct tracheal invasion : M/C

- CA thyroid, larynx, lung, esophagus
Hematogenous metastasis
- Melanoma, CA breast, colon, kidney
 Direct invasion
TRACHEAL
WELCOME! TUMOR
Metastasis

A large mass in the left lobe of the thyroid gland. Esophageal carcinoma with
The mass involves the tracheal wall and extends tracheal invasion
into the tracheal lumen.
TRACHEAL TUMOR Hematogenous
WELCOME! metastasis
Metastasis

Hematogenous metastasis from melanoma

Soft tissue mass arise from anterior tracheal wall causing tracheal lumen narrowing
TRACHEAL
WELCOME! TUMOR
Malignant
Benign
Squamous cell papilloma
Papillomatosis
Primary Metastasis
Hamartoma
Other mesenchymal Squamous cell carcinoma Direct invasion
tumors Adenoid cystic carcinoma Hematogenous
Mucoepidermoid carcinoma spreading
Carcinoid tumor
Sarcoma
Lymphoma
TRACHEAL
WELCOME! TUMOR
Squamous cell papilloma
M/C benign tracheal tumor
Abnormal proliferation of
squamous epithelium
Solitary
- Adult, associated with smoking
- A well-circumscribed nodule
confined to tracheal wall and
project to tracheal lumen with
acute angle to the wall
Papillomatosis (Multiple)
- Children, URI by HPV infection
- Involved larynx, extended to trachea
and proximal bronchus
- Multiple nodules involved entire
trachea or diffuse nodular
thickening of tracheal wall
- Multiple nodules with cavitated or
cysts
- Risk of malignant transformation to
SCC
TRACHEAL
WELCOME! TUMOR
Squamous cell papilloma : papillomatosis

Concentric thickening of Multiple polypoid nodules in trachea, multiple nodules in

tracheal wall lung, some of which are cavitated
TRACHEAL
WELCOME! TUMOR
Harmatoma

M/C benign tumor of lung, only 3%

are endobronchial
CT findings can be variable because
of its various tissue components.
(chondroid cartilage, fat, fibrous and
epithelial tissue)
Internal fat or popcorn
calcification help distinguish
hamartomas from malignancies
TRACHEAL
WELCOME! TUMOR
Harmatoma

Popcorn-like Internal fat Fat density lesion extend from posterior of

calcification density trachea causing narrowing of lumen
TUBERCULOSIS
 TUBERCULOSIS
WELCOME!

Isolated tracheal disease is rare.

Involve both the distal trachea and the proximal main bronchi
or
Active disease : Diffuse irregular wall thickening with narrowing of tracheal lumen
Result from 1. extrinsic compression from lymph nodes
2. granulomatous changes in the tracheal wall.
PostRx : Reversible or developed luminal narrowing (stricture) without wall thickening
 Active disease
TUBERCULOSIS
WELCOME!

Centrilobular nodules with Diffuse irregular thickening of tracheal wall and diffuse
tree-in-bud pattern stenosis of distal trachea and left main bronchus
 Post treatment
TUBERCULOSIS
WELCOME!

PreRx :Circumferential wall thickening and PostRx : Decreased wall thickness

luminal narrowing of trachea and increased luminal diameter
 Post treatment
TUBERCULOSIS
WELCOME!

PreRx : Wall thickening with PostRx : Improvement with smoother luminal

occlusion of left main bronchus narrowing and decrease wall thickness
TRACHEAL STENOSIS
TRACHEAL
WELCOME! STENOSIS
Postintubation stenosis

Occurs after endotracheal intubation or tracheostomy

Location :
1. At the tracheostomy opening or stoma
2. At the site of the balloon cuff
TRACHEAL
WELCOME! STENOSIS
Acute postintubation stenosis

Results from edema of the tracheal wall or

intraluminal granulation tissue
Eccentric or concentric soft tissue thickening
without evidence of deformity of outer tracheal wall
Hour-glass stenosis better seen in coronal and
sagittal images
TRACHEAL
WELCOME! STENOSIS
Acute postintubation stenosis

Focal narrowing of tracheal lumen with An hourglass-shaped tracheal

increase soft tissue, normal tracheal cartilage stenosis after intubation
TRACHEAL
WELCOME! STENOSIS
Chronic postintubation stenosis

Results from fibrosis or stricture

Deformity of tracheal cartilage and collapse of
tracheal wall>> lumen narrowing
Absent or mild thickening of the mucosa and
submucosa
The area of narrowing may be thin and weblike
or long and hourglass shaped.
TRACHEAL
WELCOME! STENOSIS
Chronic postintubation stenosis

Side-to side narrowing of tracheal lumen An hourglass-shaped stenosis with

resulting from deformity of tracheal inward collapse of tracheal wall
cartilage
 TRACHEAL NARROWING

Focal Focal/Diffuse Diffuse

Tracheal Tumors Tracheomalacia Saber-sheath Trachea

Tuberculosis Wegener’s Granulomatosis Tracheobronchopathia
Tracheal Stenosis Amyloidosis Osteochondroplastica
Sarcoidosis Relapsing
Polychondritis
TRACHEOMALACIA
TRACHEOMALACIA
WELCOME!
: Weakness of the tracheal wall, usually due to abnormalities of the tracheal cartilage
associated >> excessive collapsibility of the trachea on expiration

Cause : Congenital Acquired (common)

• Intubation injuries
• Chronic extrinsic compression : mass, vascular ring/sling
• Chronic infection
• COPD
• Association with saber-sheath trachea, relapsing
polychondritis, or tracheobronchomegaly
TRACHEOMALACIA
WELCOME!
Inspire Expire

Lunate-shaped trachea Frown sign

(Highly suggestive) Marked anterior bulging of
Coronal : Sagittal > 1 dnacorona'ssay posterior membrane
2 mm (Crescentic pattern)
TRACHEOMALACIA
WELCOME!

Dynamic CT :
Significant decrease in the tracheal diameter or
collapse of the tracheal walls with expiration
- Collapse > 50% is present in many healthy
individuals (>78%)
- Suggested cut off > 70% to avoid overdiagnosis

Chung J, Kanne J, Gilman M. CT of diffuse tracheal disease. AJR. 2011; 196:W.240-W246

 EGENE
GRANULOMATOSIS
 EGENE G AN L MA I
WELCOME!

Idiopathic necrotizing granulomatous vasculitis

History of sinus, renal disease, pulmonary cavitary
nodule or pulmonary hemorrhage
Tracheobronchial involvement occurs in about
15% to 25% of cases
Subglottic tracheal involvement is most typical
Focal or diffuse circumferential thickening of the
tracheal wall, narrowing of the tracheal lumen
 EGENE G AN L MA I
WELCOME!

Vocal cord

Excessive soft tissue internal to cricoid Subglottic stenosis : focal narrowing just
cartilage below level of vocal cord
 EGENE G AN L MA I
WELCOME!

Concentric thickening tracheal wall At the level of carina,

with tracheal narrowing bronchial wall thickening
AMYLOIDOSIS
 AMYLOIDOSIS
WELCOME!

Thoracic amyloidosis
1. Tracheobronchial amyloidosis (M/C)
2. Pulmonary nodular amyloidosis
3. Diffuse interstitial deposits (rare)
 AMYLOIDOSIS
WELCOME!

Submucosal amyloid deposition

Nodular and irregular narrowing of tracheal
lumen, often involve subglottic trachea
Bronchial stenosis or occlusion may result in
lobar or segmental atelectasis
Calcification and ossification are common ;
DDX : Tracheobronchopathia
osteochondroplastica, relapsing polychondritis
 AMYLOIDOSIS
WELCOME!

Eccentric thickening of tracheal wall

 AMYLOIDOSIS
WELCOME!

Nodular thickening and calcification

Tracheal wall thickening and focal
of the walls of the right main and RUL
thickening and calcification of bronchial
walls bronchi
SARCOIDOSIS
 SARCOIDOSIS
WELCOME!

Idiopathic multisystem granulomatous disease

Typical involve thoracic LN and lung parenchyma
Large airway involvement is uncommon
Involve upper trachea and larynx
Smooth or nodular wall thickening and lumen narrowing, calcification
Narrowing from lymphadenopathy or tracheal noncaseating granulomas
 SARCOIDOSIS
WELCOME!

Partially calcified, irregular, nodular thickening of trachea with

luminal narrowing
 TRACHEAL NARROWING

Focal Focal/Diffuse Diffuse

Tracheal Tumors Tracheomalacia Saber-sheath Trachea

Tuberculosis Wegener’s Granulomatosis Tracheobronchopathia
Tracheal Stenosis Amyloidosis Osteochondroplastica
Sarcoidosis Relapsing
Polychondritis
SABER-SHEATH TRACHEA
SABER-SHEATH
WELCOME! TRACHEA

Chronic injury of the trachea due to coughing or

increase intrathoracic pressure overtime
Associated with COPD AAA
Intrathoracic trachea : Marked decrease in coronal
diameter with an increase in its sagittal diameter
without tracheal wall thickening
Begin at the thoracic inlet and extend to distal
trachea
Coronal : Sagittal < 2/3 Sas lov rel 1.5 inn
SABER-SHEATH
WELCOME! TRACHEA

Hourglass-shaped narrowing of the

Increase tracheal diameter in
intrathoracic trachea, normal
lateral projection
extrathoracic trachea (white arrow)
SABER-SHEATH
WELCOME! TRACHEA

Normal extrathoracic trachea Side-to-side narrowing of two intrathoracic trachea

associated with deformity of tracheal cartilage
TRACHEOBRONCHOPATHIA
OSTEOCHONDROPLASTICA
 TRACHEOBRONCHOPATHIA
OSTEOCHONDROPLASTICA
WELCOME!

M > 50 yrs
Cartilaginous and osseous nodules within the
submucosa of the tracheal and bronchial walls
Thickened cartilage with small irregular
calcified nodules along their inner aspect,
protruding into the tracheal lumen
Spare posterior tracheal membrane
 TRACHEOBRONCHOPATHIA
OSTEOCHONDROPLASTICA
WELCOME!

Nodular thickening and calcification of anterior and lateral wall

Normal posterior tracheal membrane
 TRACHEOBRONCHOPATHIA
OSTEOCHONDROPLASTICA
WELCOME!

Nodules arising from anterior and Nodules arising from tracheal

lateral wall, projecting into the lumen cartilage
Normal posterior trachea
 RELAPSING
POLYCHONDRITIS
RELAPSING
WELCOME! POLYCHONDRITIS

Autoimmune disease
Recurrent episodes of cartilage inflammation most
commonly affecting the ear, nose, joints, and the
laryngeal and tracheal cartilage
limited to the cartilage and perichondrium and does
not affect the mucosa or submucosa
Diffuse smooth thickening with increase attenuation of
the anterior and lateral tracheal walls
Spare posterior membrane
Both the inner and outer margins of the thickened
tracheal walls are smooth in contour.
RELAPSING
WELCOME! POLYCHONDRITIS

Tracheal narrowing with thickening of Narrowing of main bronchus with

anterior and lateral wall thickening of anterior wall, normal
Normal posterior tracheal membrane posterior wall of bronchus
RELAPSING
WELCOME! POLYCHONDRITIS

Diffuse narrowing of trachea with Diffuse narrowing of trachea

thickening of its lateral wall
 TRACHEAL ABNORMALITY

TRACHEAL NARROWING INCREASE DIAMETER

Tracheal Tumors Tracheal Diverticulum
Tracheomalacia Mounier-Kuhn Syndrome
Tuberculosis
Tracheal Stenosis
Saber-sheath Trachea
Wegener’s Granulomatosis
Amyloidosis
Sarcoidosis
Tracheobronchopathia
Osteochondroplastica
Relapsing Polychondritis
 TRACHEAL
DIVERTICULUM
TRACHEAL
WELCOME! DIVERTICULUM

A focal herniation of tracheal mucosa through

the tracheal wall
Almost always occurs near the thoracic inlet,
along the right posterolateral trachea (between the
cartilaginous and muscular portions of the tracheal
wall)
An isolated paratracheal air cyst, usually a few
millimeters in diameter, or as an air-filled structure
communicating with the tracheal lumen
TRACHEAL
WELCOME! DIVERTICULUM

A defect at right posterolateral wall

An isolated paratracheal air cyst
communicate with a small
diverticulum
MOUNIER-KUHN
SYNDROME
MOUNIER-KUHN
WELCOME! SYNDROME

M>F, 30-40 yrs

Deficiency of smooth muscle and elastic fibers >Marked dilatation of the
trachea and mainstem bronchi
Tracheobronchomegaly
- A tracheal diameter greater than 3 cm (measured 2 cm above the aortic
arch) and diameters of 2.4 and 2.3 cm for the right and left main bronchi
Association with tracheal diverticulosis, recurrent lower respiratory tract
infections, and bronchiectasis
Cystic bronchiectasis may be seen in the central or parahilar lung regions
MOUNIER-KUHN
WELCOME! SYNDROME

Diffuse dilatation of trachea Diffuse central Tracheal corrugation on

bronchiectasis sagittal image
MOUNIER-KUHN
WELCOME! SYNDROME

CT above the aortic arch shows marked The trachea wall has a scalloped appearance
tracheal dilatation Central cystic bronchiectasis, with bullae at
periphery
TAKE HOME MESSAGE
 TRACHEAL ABNORMALITY

TRACHEAL NARROWING INCREASE DIAMETER

Tracheal Tumors Tracheal Diverticulum
Tracheomalacia Mounier-Kuhn Syndrome
Tuberculosis
Tracheal Stenosis
Saber-sheath Trachea
Wegener’s Granulomatosis
Amyloidosis
Sarcoidosis
Tracheobronchopathia
Osteochondroplastica
Relapsing Polychondritis
 TRACHEAL NARROWING

Focal Focal/Diffuse Diffuse

Tracheal Tumors Tracheomalacia Saber-sheath Trachea

Tuberculosis Wegener’s Granulomatosis Tracheobronchopathia
Tracheal Stenosis Amyloidosis Osteochondroplastica
Sarcoidosis Relapsing
Polychondritis
 FOCAL TRACHEAL NARROWING

Tracheal Stenosis Tuberculosis Tracheal Tumors

Active PostRx
Acute Chronic

Tracheomalacia
Sarcoidosis Cal.
Subglottic Wegener’s Granulomatosis
region
Amyloidosis Cal.
 TRACHEAL TUMOR

Benign Malignant

Squamous cell papilloma Smoking

Papillomatosis Child,multiple, pul.cavitary nodule Primary Metastasis
Hamartoma Fat, popcorn calcification
Mesenchymal tumors Squamous cell carcinoma Direct invasion
1st MC smoking, distal trachea CA thyroid, larynx,
lung, esophagus
Adenoid cystic carcinoma
2nd MC nonsmoking, upper trachea Hematogenous
Carcinoid tumor Vivid enhancement spreading
Mucoepidermoid carcinoma
Sarcoma, Lymphoma
 TRACHEAL NARROWING

Focal Focal/Diffuse Diffuse

Tracheal Tumors Tracheomalacia Saber-sheath Trachea

Tuberculosis Wegener’s Granulomatosis Tracheobronchopathia
Tracheal Stenosis Amyloidosis Osteochondroplastica
Sarcoidosis Relapsing
Polychondritis
 DIFFUSE TRACHEAL NARROWING
Spare Wall
posterior Cal. No wall
thickening
membrane thickening
Cal.
Tracheobronchopathia Tracheomalacia Amyloidosis Sarcoidosis
Osteochondroplastica

No Cal.
Relapsing Polychondritis Saber-sheath Trachea
Wegener’s Granulomatosis
 TRACHEAL ABNORMALITY

TRACHEAL NARROWING INCREASE DIAMETER

Tracheal Tumors Tracheal Diverticulum
Tracheomalacia Mounier-Kuhn Syndrome
Tuberculosis
Tracheal Stenosis
Saber-sheath Trachea
Wegener’s Granulomatosis
Amyloidosis
Sarcoidosis
Tracheobronchopathia
Osteochondroplastica
Relapsing Polychondritis
 INCREASE DIAMETER
Tracheal Diverticulum Mounier-Kuhn Syndrome

Tracheobronchomegaly
Central cystic bronchiectasis
Tuberculosis Early: concentric wall thickening Tracheal collapse; history of predisposing
Late: stricture or distortion of cartilage condition
or trauma
Post intubation Early: concentric wall thickening Malacia may present
stenosis Late: stricture or distortion of cartilage
Tracheomalacia Collapse of tracheal wall with expiration Tracheal collapse; history of predisposing
condition or trauma

Saber-sheath Decreased coronal diameter with Characteristic bullet-shaped trachea on axial CT,
trachea concomitant increase in sagittal diameter history of COPD

Wegener’s Concentric wall thickening Subglottic narrowing when focal; history of sinus
granulomatosis cartilage destruction or renal disease, pulmonary cavitary nodules or
pulmonary hemorrhage
Amyloidosis Concentric or nodular wall thickening

Sarcoidosis Smooth or nodular wall thickening and Hilar and mediastinal lymphadenopathy;
narrowing perilymphatic pulmonary nodules

Tracheobronchopathia Calcified submucosal nodules adjacent to Spare the posterior membrane

osteochondroplastica tracheal cartilage, nodules

Relapsing Thickening of anterior and lateral wall Spare posterior membrane

polychondritis Cartilaginous abnormalities of the ears or nose
REFERENCE
THANK YOU