Ann Thorac Surg 2005;79:686-687
© 2005 The Society of Thoracic Surgeons
Case report
Tracheocele: Surgical and Thoracoscopic Findings
Shunsuke Endo, MDa,*,
Noriko Saito, MDa,
Tsuyoshi Hasegawa, MDa,
Yukio Sato, MDa,
Yasunori Sohara, MDa
a Division of General Thoracic Surgery, Department of Surgery, Jichi Medical School, Minamikawachi-machi, Kawachi-gun, Tochigi, Japan
Accepted for publication August 28, 2003.
* Address reprint requests to Dr Endo, Division of General Thoracic Surgery, Department of Surgery, Jichi Medical School, Minamikawachi-machi, Kawachi-gun, Tochigi 329-0498, Japan
tcvshun{at}jichi.ac.jp
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Abstract
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We report a rare case of tracheocele found incidentally on a chest computed tomographic scan of a 78-year-old woman undergoing left hemithyroidectomy. The tracheocele was removed, and our operative and thoracoscopic findings are reported herein. The causes and possible clinical implications of tracheocele are discussed.
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Introduction
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Tracheocele is rarely encountered in clinical practice; its prevalence in a reported autopsy series was approximately 1% [1]. In adults, tracheocele is produced by mucosal herniation resulting from increased intraluminal pressure [2]. The radiographic features of tracheocele have been described in several reports [2, 3], but few operative findings have been described [4–6]. We herein report operative and thoracoscopic findings in a patient we treated.
A 78-year-old woman with an adenomatous goiter in the left lobe was scheduled to undergo left hemithyroidectomy. She had some coughing and some neck irritability. Blood tests were normal. Her vital capacity was 2350 mL, 106% of the predicted capacity. Forced effort volume per second was 1750 mL, 109% of the predicted volume. She had never undergone tracheal intubation nor experienced a neck injury. A paratracheal air cyst was discovered incidentally on the preoperative chest computed tomographic scan (Fig 1). The surgical retraction of the thyroid and trachea to the left cranial side during the left hemithyroidectomy performed through a neck collar incision revealed a 2 x 2 x 1 cm thin-walled cyst that mimicked a pulmonary bulla. The cyst was located between the right recurrent nerve and right carotid artery (Fig 2A). An increase in intratracheal pressure by mechanical ventilation revealed communication to a slit on the right edge of the membranous portion of the trachea at the level of the thoracic inlet, but bronchoscopy could not locate the slit. Because the cyst extended into the right upper mediastinum, right thoracoscopy was performed to clarify the relation between the cyst and the right lung. The tracheocele, located in the upper mediastinum behind the right brachiocephalic artery, had no communication with the right lung (Fig 2B). Cystectomy was performed through the neck collar incision before the left hemithyroidectomy. Microscopically, the cyst appeared to be lined by ciliated, columnar epithelia without other tracheal structures. The patient was discharged 7 days later without incident.
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Fig 1. Chest computed tomography image with lung window showing a right paratracheal air cyst and adenomatous goiter in the left thyroid lobe.
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Fig 2. Operative and thoracoscopic findings. (A) During the surgical procedure, a thin-walled cyst located between the right recurrent nerve (RRN) and right carotid artery (RCA) was found. (Cs = cyst; T = trachea; Thy = thyroid.) (B) Right thoracoscopy revealed no communication between the apical segment in the right upper lobe and the cyst within the right upper mediastinum. (L = lung; RBCA = right brachiocephalic artery; RBCV = right brachiocephalic vein.)
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Comment
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A right paratracheal air cyst in the thoracic inlet is a rarely described lesion. We showed the tracheocele to be a thin-walled cyst without mucous that mimicked a pulmonary bulla. Thoracoscopy revealed no apical lung hernia [7]. Histologically, the tracheocele showed a single layer of respiratory epithelium. The term tracheocele has been applied to acquired tracheal diverticula when they become dilated and filled with air, observed as a paratracheal transparency on a standard chest radiograph [2, 3]. This differs from congenital tracheal diverticula, which are thought to be malformed supernumerary branches of the trachea, have an anatomically complete tracheal structure, and are filled with mucus [8]. The increased intraluminal pressure responsible for the mucosal herniation underlying noncongenital tracheocele is usually due to coughing or blunt injury [1, 4, 6]. This tracheocele usually occurs on the right side, with the tracheal mucosa protruding posterolaterally through an area of weakness. It can occur in cases of chronic obstructive pulmonary disease causing chronic cough or saber-sheath tracheomalacia [2]. The patient's history and the location and histologic examination of the tracheocele generally reveal its pathogenesis. A left thyroid tumor extending into the left thoracic inlet may irritate the neck and trachea, leading to a chronic cough. In turn, a weak point in the mucosa of the right tracheal wall may gradually herniate into the looser right upper mediastinum.
Reports of the surgical treatment of such a tracheocele are uncommon because of the rarity of this condition and because the typical patient is elderly with compromised respiratory function. Surgical intervention is required when tracheal irritability occurs or when the abnormality is found in conjunction with a related procedure [4–6].
Tracheocele should be considered when a right paratracheal cyst is shown on chest radiography.
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References
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- MacKinnon DM. Tracheal diverticula. J Pathol Bacteriol. 1953;65:513–517[Medline]
- Goo JM, Im JG, Ahn JM, et al. Right paratracheal air cysts in the thoracic inlet: clinical and radiologic significance. Am J Roentgenol. 1999;173:65–70[Abstract/Free Full Text]
- Tanaka H, Mori Y, Kurokawa K, et al. Paratracheal air cysts communicating with the trachea: CT findings. J Thorac Imaging. 1997;12:38–40[Medline]
- Infante M, Mattavelli F, Valente M, et al. Tracheal diverticulum: a rare cause and consequence of chronic cough. Eur J Surg. 1994;160:315–316[Medline]
- Tanaka H, Igarashi T, Teramoto S, et al. Lymphoepithelial cysts in the mediastinum with an opening to the trachea. Respiration. 1995;62:110–113[Medline]
- Collins MM, Wight RG. Posterior tracheal wall diverticula—an unexpected findings. J Laryngol Otol. 1997;111:663–665[Medline]
- McAdams HP, Gordon DS, White CS. Apical lung hernia: radiologic findings in six cases. Am J Roentgenol. 1996;167:927–930[Abstract/Free Full Text]
- St. George R, Deslauriers J, Duranceau A, et al. Clinical spectrum of bronchogenic cysts of the mediastinum and lung in the adult. Ann Thorac Surg. 1991;52:6–13[Abstract]
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Abstract
Introduction
