Eur J Cardiothorac Surg 2008;34:916-917. doi:10.1016/j.ejcts.2008.06.022
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Tracheal diverticulum: a rare cause of dysphagia
Serdar Hana,*,
Erkan Dikmena,
Sezai Aydinb,
Osman Yapakcic
a Department of Thoracic Surgery, Ankara Guven Hospital, Ankara, Turkey
b Department of General Surgery, Ankara Guven Hospital, Ankara, Turkey
c Department of Anesthesiology, Ankara Guven Hospital, Ankara, Turkey
Received 2 April 2008;
received in revised form 29 May 2008;
accepted 9 June 2008.
* Corresponding author. Address: Department of Thoracic Surgery, Ankara Guven Hospital, Simsek Sokak No. 29, Kavaklidere, Ankara, Turkey. Tel.: +90 312 4572192; fax: +90 312 4660752. (Email: serdarhan1{at}yahoo.com).
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Abstract
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Tracheal diverticulum is a rarely encountered entity which is frequently an incidental finding in the postmortem examination, reported in 1% of patients in an autopsy series. Most cases are asymptomatic, but when symptoms are present they usually have airway symptoms with cough or recurrent respiratory infection. We herein report a case of a tracheal diverticulum, which had cervical dysphagia and sensation of friction.
Key Words: Trachea • Diverticulum
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1. Introduction
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Tracheal diverticulum is a paratracheal air cyst representing an out pouching of the tracheal wall. It may be congenital or acquired, the difference residing mainly in the histological features of the wall. Tracheal diverticulum is frequently an incidental finding in the postmortem examination, reported in 1% of patients in an autopsy series [1]. Most cases are asymptomatic, however they can act as a reservoir for secretions with secondary chronic infections of the tracheobronchial tree. Therefore, tracheal diverticula may present clinically with chronic cough, dyspnea, stridor, and repeated episodes of tracheobronchitis [2]. Imaging techniques are useful for diagnosis, because the point of communication with the trachea is difficult to detect with bronchoscopy [3]. In the absence of symptoms, management should be conservative. We herein report a case of tracheal diverticulum that presented with dysphagia and sensation of friction.
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2. Case report
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A 50-year-old man was admitted to our hospital with episodes of mild cervical dysphagia and sensation of friction. He had no history of smoking and was taking any medications. Physical examination revealed no abnormal findings and barium contrast study was normal (Fig. 1
). The CT scan of the chest and neck showed a 3 cm x 3 cm tubular air-filled structure, which was adjacent to the posterolateral wall of the trachea at the level of thoracic inlet. There was no calcification and no evidence of wall thickening within this lesion. Additionally, no connection was noted between the lesion and trachea on coronal images (Fig. 2A). However, sagittal CT images revealed 3 mm wide connection between the trachea and air-filled structure (Fig. 2B). Fiberoptic esophagoscopy and bronchoscopy were also non-diagnostic and we were not able to observe communication with the trachea and diverticulum. When the patient was operated with right semi collar incision, we observed that paratracheal air had filled the lesion; it was originated from the right side of the posterior tracheal wall and the diverticulum was excised totally. Histopathologic examination revealed that the cyst was lined by a respiratory mucosa, and the walls showed presence of cartilage and mucus glands. The lesion was diagnosed as the diverticulum of trachea. Postoperative course was uneventful and the patient remained well and symptom-free 2 years following surgery.
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Fig. 2. (A) Coronal CT image showing tracheal diverticulum. (B) Sagittal CT image showing connection between trachea and diverticulum.
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3. Discussion
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Tracheal diverticulum is a very rare entity and four types of tracheal diverticula have been described by Katz et al.; rudimentary bronchus, cystic dilatation of mucous gland duct, tracheocele, and diverticulum associated with tracheobronchomegaly [4]. Tracheocele typically present as a single, large, air-containing sac, which develops through a localized weakness in the right posterior tracheal wall as seen our patient. This may be formed by prolonged increase in intratracheal pressure from violent coughing or from an occupation involving excessive vocal or pulmonary effort. Our patient had no history of predisposition, thus we think that it is a congenital lesion. Such a diverticulum may present radiographically as a paratracheal or superior mediastinal air cavity, with or without an air-fluid level. The few reported cases of tracheal diverticula in the literature speculate regarding the etiology and clinical significance of such abnormalities. The preponderant right-sided location of the diverticula may reflect the relatively weak structural support on the right side of the trachea. The esophagus and aortic arch provide support to the left side of the airway and thus make the left tracheal wall less susceptible to the development of diverticula.
The described case had very rare presentation as dysphagia. Large posterior tracheal wall diverticula may compress the esophagus and cause dysphagia. The differential diagnosis of a paratracheal air collection includes pharyngocele, esophageal diverticulum, laryngocele, apical hernia of the lung, and apical paraseptal blebs or bullae [5]. Both barium contrast study and CT scan of the neck and chest are useful noninvasive techniques for differential diagnosis. In addition, fiberoptic esophagoscopy and bronchoscopy are adjacent invasive techniques for diagnosis. In most previously reported cases, paratracheal air cysts were identified at routine chest radiography and CT, and were located at the right posterolateral aspect of the trachea at the level of the T1–T2 vertebral body.
In conclusion, tracheal diverticula is a rare entity, commonly seen on right side, producing very few symptoms and is frequently an incidental finding on post mortem. The present case demonstrates the importance of keeping a tracheal diverticula in mind while dealing with dysphagy. Surgical therapy is an effective solution in symptomatic tracheal diverticula cases and outcomes are favorable as in our case.
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References
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- Goo JM, Im J, Ahn KM, Moan WK, Chung JW, Park JH, Seo JB, Han MC. Right paratracheal air cysts in the thoracic inlet: clinical and radiologic significance. AJR Am J Roentgenol 1999;173:65-70.[Abstract/Free Full Text]
- Early EK, Bothwell MR. Congenital tracheal diverticulum. Otolaryngol Head Neck Surg 2002;127:119-121.[CrossRef][Medline]
- Tanaka H, Mori Y, Kurokawa K, Abe S. Paratracheal air cysts communicating with the trachea: CT findings. J Thorac Imaging 1997;12:38-40.[Medline]
- Katz I, Levine M, Herman P. Tracheobronchomegaly. Am J Roentgenol 1962;88:1084-1089.
- Infante M, Mattavelli F, Valente M, Alloisio M, Preda F, Ravasi G. Tracheal diverticulum: a rare cause and consequence of chronic cough. Eur J Surg 1994;160:315-316.[Medline]
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Abstract
1. Introduction
