Nonneoplastic Tracheal and Bronchial Stenoses

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Nonneoplastic stenosis of proximal airways may result from longstanding intubations or tracheostomy, granulomatous infection, or systemic diseases such as relapsing polychondritis, amyloidosis, Wegener's granulomatosis, sarcoidosis, and inflammatory bowel disease. It also may be caused by saber sheath trachea, tracheobronchopathia osteoplastica, or broncholithiasis. An early diagnosis of the tracheal and bronchial stenosis has become possible with the advent of routine CT imaging. Multiplanar and volume rendering reformations after thin collimation MDCT acquisition help assess the location and extent of the stenosis and characterize the presence, distribution, and type of airway wall thickening. They also help surgeons and endoscopists to select adequate procedures and assess the response to treatment.

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Iatrogenic stenosis

The most common iatrogenic airway stenoses are tracheal strictures secondary to intubation or tracheostomy and bronchial anastomosis stenosis after lung transplantation. Strictures of the trachea are usually secondary to damage from a cuffed endotracheal or tracheostomy tube. The prevalence of stenoses after endotracheal tube placement has decreased substantially to 1% since the introduction of low pressure cuff endotracheal tubes.10 Conversely, the prevalence of tracheal stenosis after

Tuberculosis

Tracheobronchial stenosis caused by tuberculosis may occur in the setting of acute infection or as late as 30 years after infection.14 Endobronchial tuberculosis has been reported in 10% to 37% of patients with pulmonary tuberculosis, and a variable degree of stenosis has been reported to occur in 90% of cases.14 Isolated tracheal involvement is likely a rare manifestation. Tuberculosis typically involves the distal trachea and proximal bronchi. Spread along peribronchial lymphatic channels

Bronchial anthracofibrosis

Bronchial anthracofibrosis recently was defined as an inflammatory bronchial stenosis associated with anthracotic pigmentation on bronchoscopy without a relevant history of pneumoconiosis or smoking. Most patients with bronchial anthracosis have had no exposure to mining or industry and no history of smoking. A potential relationship between bronchial anthracosis and tuberculosis has been suggested, however. It has been hypothesized that the black pigments in the bronchial walls are derived

Rhinoscleroma

Rhinoscleroma is a slowly progressive infectious granulomatous disease caused by Klebsiella rhinoscleromatis, a capsulated gram-negative bacterium that is endemic in tropical and subtropical areas.23, 24 Typically involving the upper respiratory tract, this organism also may involve the trachea and proximal bronchi. If left untreated, the infection progresses slowly over many years with alternating periods of remission and relapse. Pathologically in the granulomatous phase, nodules and masses

Fungal tracheobronchitis

Acute tracheobronchitis caused by aspergillosis is uncommon and is usually restricted to the central airways. It usually occurs in severely immunocompromised individuals, especially persons with underlying malignancies or AIDS, or in individuals who have undergone bone marrow, lung, or heart transplantation.25 Histologically, there is evidence of respiratory epithelial ulceration and submucosal inflammation. CT reveals nonspecific multifocal or diffuse tracheobronchial wall thickening, which

Relapsing polychondritis

Relapsing polychondritis is an unusual multisystemic disease of unknown origin that is characterized by recurrent inflammation of the cartilaginous structures of the nose, external ear, peripheral joints, larynx, trachea, and bronchi.29 Relapsing polychondritis is likely immune-mediated and considered to have an autoimmune pathogenesis. Although any age group may be affected, the peak of incidence of the disease is between the third and the sixth decades with a slight predominance in women.

Wegener's granulomatosis

Wegener's granulomatosis is a disease of unknown origin that is characterized by a necrotizing granulomatous vascularitis. Involvement of the large airways is a common manifestation of the disease. Its frequency was reported as 16% and 23% in two large series.38, 39 Although most often unassociated with symptoms or a late manifestation of well-established disease, tracheal or bronchial stenosis is occasionally responsible for the initial presentation.40 Subglottic stenosis may occur in

Tracheobronchial amyloidosis

Deposition of amyloid in the tracheal bronchi may be seen in association with systemic amyloidosis or as an isolated manifestation.49, 50 Airway involvement may be focal, multifocal, or diffuse. Diffuse involvement is most common. It may involve the larynx, trachea, main bronchi, and lobar or proximal segmental bronchi and often involves contiguous segments of the airway. Histologically the amyloid tends to be deposited initially in relation to tracheal gland acini and the walls of small blood

Sarcoidosis

Involvement of the trachea is rare, and when it occurs, it is usually associated with laryngeal involvement.60 The proximal and distal parts of the trachea may be affected, and the appearance of the stenosis may be smooth, irregular and nodular, or even mass-like. Bronchial involvement is much more common as a manifestation of sarcoidosis.61 It was reported in 65% of 60 patients with sarcoidosis in a study by Lenique and colleagues62 using high resolution computed tomography. The most common

Inflammatory bowel disease

Chronic inflammatory bowel diseases, including ulcerative colitis and Crohn's disease, occasionally may demonstrate extraintestinal manifestations. Among them, airway disease is relatively uncommon and may take several forms, including ulcerative tracheitis and tracheobronchitis, bronchiectasis, and small airway disease, most commonly obliterative bronchiolitis.68, 69, 70 Tracheobronchial complications are rare and occur more often in association with ulcerative colitis than Crohn's disease. In

Saber sheath trachea

Sabear sheath trachea is a relatively uncommon deformity of the trachea characterized by reduction in coronal diameter and elongation of the sagittal diameter. It is defined by a coronal diameter equal to or less than one-half its sagittal diameter, measured at 1 cm above the top of the aortic arch.71, 72 This deformity affects only the intrathoracic portion of the trachea, with abrupt widening of the tracheal lumen above the thoracic inlet. It may extend downward on the mainstem bronchi. This

Tracheobronchopathia osteochondroplastica

This rare disorder is characterized by the presence of multiple submucosal cartilaginous or bony nodules projecting into the tracheobronchial lumen.12, 13, 14, 75 It is a benign disease of unknown origin. Men are more frequently involved than women, and most patients are older than age 50. Several potential causes or associations have been postulated, including amyloidosis, hereditary factors, chemical irritation, and infection. Most cases are asymptomatic, but patients may present with chronic

Broncholithiasis

Broncholithiasis is a condition in which calcified lymph nodes distort and erode into the tracheobronchial tree, and patients may expectorate or aspirate the calcified material.80 Most broncholiths are composed of fragments of calcified material that were originally located in a peribronchial lymph node. Broncholithiasis is considered as a late complication of granulomatous lymphadenitis caused by Mycobacterium tuberculosis or fungi such as Histoplasma capsulatum. Pathologically the airway is

Summary

MDCT using thin collimation and postprocessing techniques, such as multiplanar reformations along and perpendicular to the central axes of the central airways, and volume rendering techniques, such as virtual bronchoscopy and virtual bronchography, has become the imaging modality of choice for the diagnosis of nonneoplastic tracheal and bronchial stenoses. It may ensure accurate assessment of the location and extent of the stenosis and good characterization of the presence, distribution, type,

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      Fungi, particularly Aspergillus, may cause tracheobronchitis in immunocompromised hosts, such as those with AIDS, underlying malignancy, or after transplant. Epithelial ulceration and submucosal inflammation occurs and may lead to strictures, whereas deeper bronchial wall necrosis may lead to bronchial or bronchovascular rupture and death.3 Bronchial anthracofibrosis demonstrates characteristic bronchoscopic findings in the absence of known pneumoconiosis or smoking.3

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