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com CASE REPORT

Radiographic and computed

tomographic appearance of tracheal
collapse with axial rotation in four dogs
H. G. Heng1, C. K. Lim, B. Gutierrez-Crespo and L. F. Guptill

Department of Veterinary Clinical Sciences, Purdue University, West Lafayette, IN 47907, USA
1
Corresponding author email: hheng@purdue.edu

Tracheal collapse with axial rotation was diagnosed in four dogs. Radiographs showed increased
tracheal dorsoventral height at the caudal cervical and thoracic inlet with and apparent intraluminal
soft tissue opacity, mimicking an intraluminal tracheal foreign body. Computed tomography confirmed
dorsoventral tracheal collapse with axial rotation in all dogs. Short-term outcome with medical
treatment of all dogs was excellent.

Journal of Small Animal Practice (2017)

DOI: 10.1111/jsap.12679
Accepted: 8 January 2017

INTRODUCTION HISTORY AND PHYSICAL EXAMINATION

Tracheal collapse is commonly seen in middle-aged small-breed Case 1

dogs. Its aetiology is multi-factorial and currently poorly under-
stood (Tappin 2016). Patients with tracheal collapse will normally
be presented with paroxysmal, persistent dry harsh cough, com-
monly described as “goose-honking” (Maggiore 2014).
The diagnosis of tracheal collapse in dogs is based on dis-
tinct narrowing of the dorsoventral tracheal height and is com-
monly made using radiography and fluoroscopy (Macready
et al. 2007). Radiography underestimates the frequency and
severity of collapse when compared with fluoroscopy (Macready
et al. 2007). Ultrasonographic detection of change in the tracheal
shape because of tracheal collapse has been reported (Rudorf
et al. 1997), but is limited to the cervical region and the thoracic
inlet (Eom et al. 2008). Recently, computed tomography (CT)
has been used to diagnose collapsing trachea in dogs (Stadler et al.
2011). One of the advantages of CT is the ability to image the
patient without anaesthesia and with minimal physical restraint,
thus reducing stress to the patient (Stadler et al. 2011). Broncho-
scopic evaluation and classification of tracheal collapse has been
reported and compared with fluoroscopy and radiography (Bot-
tero et al. 2013, Johnson et al. 2015). Additional information
such as detection of airway inflammation and collection of sam-
ple for cytology evaluation can be acquired with bronchoscopy.
This study describes the CT appearance of dorsoventral tra-
cheal collapse and axial rotation in four dogs.
A 10-year-old neutered male, Yorkshire terrier was presented with
an acute episode of progressively increasing inspiratory effort and
became dyspnoeic with excitement after having been sedated by the
referring veterinarian. Physical examination findings included: tem-
perature 38·9°C, pulse 60 beats/minute, respiratory rate 30 breaths/
minute (sedated) with marked effort. Body condition score was 5 of
9. There was stertor with referred upper airway sounds on thoracic
auscultation. There was no prior history of cough. Complete blood
count (CBC) values were within reference ranges. A serum biochem-
istry panel showed a mild increase in alkaline phosphatase activity.
Case 2
An 11-year-old spayed female Chihuahua was presented with a
two-day history of acute onset progressive respiratory distress and
a “goose-honk” cough. The cough started immediately after the
dog ate a treat and continued till presentation two days later. This
dog had prior episodes of a “goose-honk” cough over a period
of several months, each lasting a few days and resolving without
medical therapy. Physical examination findings included: temper-
ature 38·9°C, pulse 130 beats/minute, respiratory rate 24 breaths/
minute. Body condition score was 8·5 of 9. A CBC showed mild
erythrocytosis, and elevated serum protein, consistent with dehy-
dration. A serum biochemistry panel showed mild increase in alka-
line phosphatase and alanine aminotransferase activities.

Journal of Small Animal Practice • © 2017 British Small Animal Veterinary Association 1
 H. G. Heng et al.

Case 3
A 7-year 10-month-old spayed female Chihuahua was presented
for re-evaluation of mitral and tricuspid valvular endocardiosis.
This dog had a two-month history of a “goose-honk” cough
when excited, but no respiratory signs at presentation. The onset
of coughing episodes coincided with diagnosis of congestive
heart failure secondary to valvular endocardiosis. The coughing
episodes persisted after treatment for congestive heart failure.
Physical examination findings included: temperature 39·7°C,
pulse 128 beats/minute, respiration panting with reverse sneez-
ing. Body condition score was 8·5 of 9. There was a mild increase
in serum alkaline phosphatase activity.
Case 4
A 14-year 1-month-old neutered male Yorkshire terrier was
presented for evaluation of chronic, frequent episodes of a
“goose-honk” cough. Physical examination findings included:
temperature 39·0°C, pulse 120 beats/minute, respiration
28 breaths/minute. Body condition score was 5 of 9. A cough was
elicited on tracheal palpation, there were referred upper respira-
tory sounds on thoracic auscultation, normal bronchovesicular
sounds and no murmurs or arrhythmias were noted. There was
an inflammatory leucogram, mild hyperglobulinaemia and mod-
erately increased hepatic enzyme activities.
Radiographic findings
All four dogs had left lateral recumbency and ventrodorsal radio-
graphs. Increased dorsoventral tracheal height was observed in all
dogs at the caudal cervical and/or cranial thoracic region (Figs 1
and 2). Focal intraluminal soft tissue opacities observed in the
trachea of all dogs at the site of increased dorsoventral tracheal
height were suspected to be foreign bodies. In Dogs 1 and 3,
there was gas surrounding the intraluminal soft tissue opacity,
creating the appearance of a short tubular soft tissue structure
within the trachea (Figs 1B and 2B). The lungs of all dogs were
normal. Dog 3 also had cardiomegaly with enlarged pulmonary
veins and compression of one main-stem bronchus.
CT findings
All dogs were positioned in sternal recumbency for CT of the
entire neck and thoracic cavity to further investigate the possibil-
ity of intratracheal foreign body. The CT study of Dog 1 was per-
formed under general anaesthesia, while those of Dogs 2, 3 and 4
were performed under sedation. CT revealed collapse of the entire
length of trachea in Dogs 1, 3 and 4. In Dog 2, the entire cervical
and cranial thoracic trachea was collapsed, but the caudal thoracic
trachea was normal. Complete central dorsoventral collapse of the
trachea at the caudal cervical/cranial thorax was apparent in Dogs
1, 2 and 4 and there was a near-complete collapse in Dog 3.
All dogs had axial rotation of the trachea. In Dog 1 (Fig 3),
clockwise axial rotation (as observed from a cranial aspect) of the
trachea started immediately caudal to the larynx and the maximal
degree of rotation (45°) was at the level of the first thoracic ver-
tebra. Subsequently, there was anticlockwise axial rotation at the
level of third thoracic vertebra. Cranial to the carina, there was
still a 23° clockwise axial rotation of the trachea. Dorsal protru-
sion of ventral wall of the trachea created an “n” shape invagina-
tion leading to complete central tracheal collapse with gas on

FIG 1. Left lateral radiographs of Dogs 1 (A) and 2 (B) and magnified views of the caudal cervical and cranial thoracic trachea (B and D). There is
increased dorsoventral diameter of the trachea and apparent intraluminal soft tissue opacity in both dogs (black arrows). This is more obvious in Dog 1

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 Tracheal collapse with axial rotation in dogs

FIG 2. Left lateral radiograph of Dog 3 (A) and right lateral radiograph of Dog 4 (C) and the magnification of the caudal cervical and cranial thoracic
trachea (B and D). There is increased dorsoventral diameter of the trachea in both dogs and there appears to be an intraluminal soft tissue tubular
opacity in Dog 3 (A and B) and ill-defined intraluminal opacity in Dog 4 (black arrows)

FIG 3. Transverse CT images of Dog 1 in lung window. The images start from cranial to caudal (A to F). At the level of caudal aspect of the larynx.
Note the endotracheal tube (A). Clockwise axial rotation of the trachea immediately caudal to the larynx (B). There is mild dorsal protrusion of the
ventral wall of the trachea, with decreased dorsoventral diameter at the level of C6 (C). There is complete tracheal collapse (black arrow) at the level
of T1, with an “n” shape appearance because of gas on the lateral aspect of the trachea (white arrows) and persistent clockwise rotation (D). There
is a reduced degree of collapse trachea at the level of T2, with a lesser degree of axial rotation (E). Mild dorsoventrally collapsed trachea just cranial
to the carina, with mild rotation (F)

both lateral aspects (Fig 3D). Tracheoscopic findings were consis- the level of T1. There was ventral protrusion of the dorsal trachea
tent with Grade IV tracheal collapse. In Dog 2 (Fig 4), the clock- membrane with gas on both lateral aspects, giving a “u” shape
wise axial rotation of the collapsed trachea started at the level of invagination to the tracheal lumen (Fig 4D). The caudal thoracic
fourth cervical vertebra, and maximal rotation (50°) occurred at trachea was in a normal anatomic position and alignment. In

Journal of Small Animal Practice • © 2017 British Small Animal Veterinary Association 3
 H. G. Heng et al.

FIG 4. Transverse CT images of Dog 2 in lung window. CT was performed with sedation and a towel was used to position the dog, this is seen outside
the body of the dog. The images start from cranial to caudal (A to F). At the level of the caudal aspect of the larynx, there is no endotracheal tube
(A). There is mild ventral protrusion of the dorsal tracheal membrane at the level of C3 (B). There is near total dorsoventral collapse (white arrow)
with axial clockwise rotation of the trachea at the level of C6. It has a “u” shaped appearance (C). A near-complete dorsoventrally collapsed trachea
with maximal axial clockwise rotation at the level of T1. There is a small amount of gas at the lateral aspect of the trachea (black arrows) (D). At the
level of T2, there is axial anticlockwise rotation of the trachea, causing reduction of angle of axial rotation. There is still severe dorsoventral collapse
(E). Absence of tracheal axial rotation just cranial to carina (F)

FIG 5. Transverse CT images of Dog 3 in lung window. The images start from cranial to caudal (A to F). There is moderate dorsoventral tracheal
collapse without any axial rotation at the level of C4 (B). There is further collapse of the trachea, and maximal axial clockwise rotation at the level of
C7. Note that there are hyperattenuating streaking artefacts originating from the trachea due to summated thickness of the tracheal wall (C). There
is still severe dorsoventral collapse of the trachea without axial rotation at the level of T1, due to anticlockwise rotation cranial to this location (D).
Further anticlockwise rotation at the level of T2 (E). There is still dorsoventral compression but without axial rotation of the trachea (F)

Dog 3 (Fig 5), there was clockwise axial rotation of the trachea
at the caudal cervical and cranial thoracic region. Anticlockwise
axial rotation of the trachea was noted at the level of first thoracic
vertebra, subsequently returned to the normal axis and then con-
tinued with anticlockwise rotation caudally. In Dog 4 (Fig 6),
clockwise axial rotation started at the level of cranial aspect of
sixth cervical vertebra. The maximum rotation was 38° at the
level of seventh cervical vertebra. The trachea then rotated back
in an anticlockwise direction. However, there was still a 22° axial
rotation immediately cranial to the carina. The trachea had a “u”

4 Journal of Small Animal Practice • © 2017 British Small Animal Veterinary Association
 Tracheal collapse with axial rotation in dogs

FIG 6. Transverse CT images of Dog 4 in lung window. There is dorsoventral collapse of the trachea at the caudal aspect of the larynx (A). Further
dorsoventral collapse of the trachea just caudal to the larynx (B). There is clockwise axial rotation of the trachea at the level of C5 (C). Total tracheal
collapse with maximum clockwise axial rotation at the level of C7. Note that there is mild ventral protrusion of the dorsal tracheal membrane with
total collapse at the middle, and small amount of gas at the lateral aspect of the trachea. It appears as a “u” shape (D). The degree of the tracheal
collapse and the degree of axial clockwise rotation is reduced at the level of T2 (E). There is mild dorsoventral collapse of the trachea with mild axial
clockwise rotation just cranial to the carina (F)

FIG 7. Transverse (A) and reconstructed sagittal (B) CT images of Dog 3. Note that there is a small amount of gas at the lateral aspect of the
dorsoventral collapsed trachea with axial rotation (black arrows) (A). The air at the lateral aspect of the collapsed trachea produces an artefact which
appears as an intraluminal tubular soft tissue opacity (B)

shape invagination at the level of C7 (Fig 6D). Narrowing of
the left main-stem bronchus was evident in Dogs 1, 2 and 3.
Multi-planar reconstruction of Dog 3 showed luminal gas on the
lateral aspects of invaginated wall of the collapsed trachea which
produced the artefactual appearance of an intraluminal tubular
soft tissue tracheal foreign body (Fig 7B).
Fluoroscopy
Fluoroscopic examination was performed in Dogs 1 and 2. In
Dog 1, there was dorsoventral dynamic collapse of the caudal cer-
vical trachea. In Dog 2, there was dorsoventral dynamic collapse
at the thoracic inlet. Bronchial collapse was detected in both
dogs. Fluoroscopy was not performed in Dogs 3 and 4 because of
financial constraints.
Treatment and clinical outcome
Each dog was managed individually, depending on the severity of
the clinical condition and owner preference. Consent for tracheal
wash with cytology and culture was not obtained for any of the
dogs. For all dogs, environmental management and management
of physical activity were discussed in detail with the owners, and
use of body harnesses rather than neck collars was recommended.
For overweight dogs, weight management protocols were created
and the importance of weight management was emphasised dur-
ing owner education. The use of cough suppressants, anti-inflam-
matory medications, anxiolytics and antibiotics varied with dogs
and their histories, clinical findings and owner preferences.
Dogs 1 and 2 did well for seven months, and were then
lost to follow-up. Dog 3 did well for six months, and was also

Journal of Small Animal Practice • © 2017 British Small Animal Veterinary Association 5
 H. G. Heng et al.
subsequently lost to follow-up. Dog 4 was doing well at the time
of writing, eight months after diagnosis.
DISCUSSION
All dogs in this study were middle-aged and of small-breed,
consistent with reported prevalence of tracheal collapse. Dogs 1
and 3 were presented with a history and clinical signs of tracheal
collapse but Dog 2 was presented with a suspicion of a tracheal
foreign body obstruction because of the history to acute onset of
clinical signs following ingestion of a treat.
Radiographic findings of all four dogs with tracheal collapse
were atypical as none of the dogs had classical signs of dorso-
ventral narrowing of the tracheal lumen (O’Brien et al. 1966,
Macready et al. 2007). Instead, all radiographs showed increased
dorsoventral tracheal dimension with the appearance of presence
of “an intraluminal soft tissue tubular opacity”, which could have
been misdiagnosed as tracheal foreign body, granuloma or neo-
plasia (Roach & Krahwinkel 2009). Also, it is possible to argue
that the increased luminal dimension alone may be attributable
to normal respiratory dimension change (Leonard et al. 2009) or
laterolateral tracheal collapse (Johnson et al. 1993).
CT confirmed that there was axial rotation of the trachea in
all four dogs. This condition is not well documented in the vet-
erinary literature even though a veterinary radiology textbook
suggested that mild tracheal rotation in dogs may be common
(Muhlbauer & Kneller 2013). Tracheal torsion causing complete
obstruction of the caudal thoracic trachea has been reported on
one dog (Portier & Viguier 2009) and tracheal rotation and dis-
placement have been noted in both radiographs and ultrasound
of dogs with tracheal collapse (Eom et al. 2008). However, there
is little information regarding the prevalence and clinical signifi-
cance of tracheal rotation, including the clinical signs, prognosis
and treatment options. This prevalence of dorsoventral tracheal
collapse with axial rotation may well have been previously under-
estimated because CT has not been widely used for diagnosing
tracheal collapse in dogs. Furthermore, radiographic detection of
increased dorsoventral tracheal dimension often implies laterolat-
eral tracheal collapse.
CT findings of all four dogs in this study confirmed that the
apparent increased dorsoventral luminal dimension was artefac-
tual and resulted from axial rotation of the collapsed trachea.
The perceived dorsoventral luminal dimension on radiography
is actually the laterolateral dimension of the trachea that was
increased as a result of dorsoventral tracheal collapse. The appar-
ent intraluminal soft tissue opacity is the contact area between
the dorsal tracheal membrane and with the ventral aspect of the
tracheal wall, made more conspicuous by small amounts of intra-
luminal gas in the lateral aspects of the tracheal lumen at the site
of collapse. Although CT showed an incomplete collapse of the
trachea in Dog 3, this may be artefactual because tracheal col-
lapse is dynamic (Macready et al. 2007).
6 Journal of Small Animal Practice
In future, CT may be indicated for assessment of tracheal axial
rotation for the placement of tracheal stents. Dogs with tracheal
axial rotation may encounter higher probability of stent fracture
as occurs in humans (Yu et al. 2010).
CONCLUSION
This study demonstrates that tracheal collapse with axial rotation
in dogs may lead to radiographic increased dorsoventral tracheal
dimension with/without intraluminal soft tissue opacity. Aware-
ness of this condition is important and should be considered as a
radiographic differential diagnosis in dogs with suspected intralu-
minal tracheal foreign body. CT should be considered to confirm
collapsing trachea with axial rotation, and excluding intralumi-
nal mass in cases where the dorsoventral dimension is increased.
Although most of the dogs in this study were subsequently lost in
follow-up, we considered that most of the dogs responded well to
medical therapy for at least six months.
Conflict of interest
None of the authors of this article has a financial or personal
relationship with other people or organisations that could inap-
propriately influence or bias the content of the paper.
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