Ann Thorac Surg 2006;82:1900-1901
© 2006 The Society of Thoracic Surgeons
Case Reports
Tuberculosis of the Trachea
Belhassen Smati, MDa,*,
Mohamed Sadok Boudaya, MDa,
Aïda Ayadi, MDb,
Jemal Ammar, MDc,
Habiba Djilani, MDa,
Faouzi El Mezni, MDb,
Tarek Kilani, MDa
a Department of Thoracic Surgery, Abderrahmen Mami Hospital, Ariana, Tunisia
b Department of Pathology, Abderrahmen Mami Hospital, Ariana, Tunisia
c Department of Pneumology, Abderrahmen Mami Hospital, Ariana, Tunisia
Accepted for publication February 13, 2006.
* Address correspondence to Dr Smati, Department of Thoracic Surgery, Abderrahmen Mami Hospital, 2080 Ariana, Tunisia. (Email: belhassen_smati{at}yahoo.fr).
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Abstract
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Tracheal tuberculosis is an uncommon localized form of tuberculosis with fewer than 150 reported cases in the literature. We report a case of tracheal stenosis caused by tuberculosis in which the diagnosis was suggested by the patient's past medical history. This patient was successfully treated with tracheal resection, adjuvant steroids and anti-tuberculous therapy. This report will review the various types of tuberculosis of the trachea and their clinical features in addition to discussing the different available treatment modalities.
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Introduction
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Tuberculosis involving the central airway occasionally results in diffuse airway stenosis, which may lead to respiratory failure in the acute phase [1]. Because other pathologies such as bronchogenic carcinoma, bronchial asthma, congenital causes, infection inhalational burns, and a myloid deposits have features that overlap with those of tuberculosis on both clinical and radiographic examination, diagnosis may be problematic.
We present a patient with a diffuse form of tuberculosis that was successfully treated with tracheal resection and anti-tuberculous therapy. The patient is a 42-year-old woman who had a past medical history of anti-tuberculous therapy for cervical tuberculous lymphadenitis who presented with cough, wheezing, and recurrent progressive dyspnea. The patient could not walk because of severe pelvic pain and weakness in the leg. The chest roentgenogram was within normal limits. Flexible bronchoscopy showed a stenosis at the level of the left choanal that was not dilatable. On the right, an atrophied choanal was also present, but it was impossible to pass a tracheal tube (size, 7 to 9 mm internal diameter) further than 3 cm beyond his vocal cords before firm resistance was felt. Tracheal biopsy specimen revealed chronic inflammation of the submucosa and tubercular lesion or malignancy was absent. A computed tomographic scan demonstrated extensive thickening of the walls of the trachea with luminal narrowing at 33 mm from the origin of the trachea and the stricture was 20 mm long (Fig 1). There were bilateral cervical and mediastinal nodes. Needle biopsy of the cervical nodes was compatible with tuberculosis. The pelvis roentgenogram showed a de-mineralized aspect of the ischio-pubic branches and fracture of the right ilio-pubic branch. A 2.5-cm segment of trachea was resected and primary anastomosis was performed. The approach was a transverse cervical incision using jet ventilation. Frozen section suggested a benign neoplasm, but a specific tissue diagnosis was not available. Immediately the patient was extubated, and intravenous dexamethasone and tuberculous therapy were given postoperatively. The postoperative course was uneventful with no evidence of recurrence 1 year after the operation. The bony fractures healed and the patient was able to walk again.
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Fig 1. Computed chest tomographic scan demonstrates an extensive thickening of the walls of the trachea.
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Comment
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In the development of tracheal tuberculosis, the first mechanism is the spread along the peribronchial lymphatic channels or the direct trachea spread by infected sputum. The second mechanism is local extension from adjacent mediastinal tuberculous lymphadenitis [2, 3]. In our patient, the history of cervical tuberculous lymphadenitis, the normal chest roentgenogram without lung parenchymal abnormality, and the contingunous of the trachea and lymphadenopathy on computed tomographic scans suggested that local extension was the most likely mechanism. Patients with central airway lesions can be classified into two different groups: (1) an active disease group and (2) a fibrotic disease group.
Stenosis in active disease occurs by hyperplastic changes and inflammatory edema. On computed tomographic scans, irregular luminal narrowing with wall thickening, contrast enhancement, and enlarged adjacent mediastinal nodes were the findings in our patient.
Stenosis in fibrotic disease occurs by fibrostenosis, and tuberculomas are usually absent in the diseased bronchial wall. On computed tomographic scan, smooth narrowing of the trachea lumen with minimal wall thickening is typically seen.
Acute ulcerative tuberculous tracheitis is treated medically. Polypoid tissue and then cicatricial stenosis may result as the tracheitis heals. This can occur despite adequate treatment of the tuberculosis. Stenosis in fibrotic disease is resistant to medical treatment and radiologic or surgical intervention is usually needed to restore the luminal patency. The helical computed tomographic scan with two-dimensional or three-dimensional images of the tracheobronchial tree gives more information in the evaluation of the central airways stenosis, which may be useful in evaluations before surgical resection, balloon bronchoplasty, or insertion of stents [4]. When the stenosis is more limited in extent, surgical excision and reconstruction can be performed, with the high likelihood of a good result. The linear extent of the tracheal stenosis may be such that excision and reconstruction may not be possible [1]. This leaves the possibility of dilatation and stenting [5]. In our patient, the inflammatory stenosis was limited to 2 cm and was considered a favorable situation for surgical treatment followed by corticotherapy and anti-tuberculous therapy.
In the active form of tracheal tuberculosis, anti-tuberculous therapy is the treatment of choice, but in some cases resection is needed because of acute dyspnea.
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Acknowledgments
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We thank Dr Claude Deschamps, Department of General Thoracic Surgery, Mayo Clinic, Rochester, MN, for his scientific and linguistic assistance.
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References
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- Bhalla M, Grillo HC, McLoud TC, Shepard JO, Weber AL, Mark EJ. Idiopathic laryngotracheal stenosis: radiologic findings AJR Am J Roentgenol 1993;161(3):515-517.[Abstract/Free Full Text]
- Kyung M, Jung GI, Kyung MY, Chung H. Tuberculosis of the central airways: CT findings of active and fibrotic diease AJR 1997;169:649-653.[Abstract/Free Full Text]
- Yasuo I, Teruomi M, Noriaki K, et al. Interventional bronchoscopy in the management of airway stenosis due to tracheobronchial tuberculosis Chest 2004;126:1344-1352.[Abstract/Free Full Text]
- Schmidt B, Olze H, Borges A, et al. Endotracheal balloon dilatation and stent implantation in benign stenoses Ann Thorac Surg 2001;71:1630-1634.[Abstract/Free Full Text]
- Huang PM, Chen JS, Hsu HH, et al. Staged dilatation and stenting for long segmental tracheobronchial stenosis caused by tuberculosis J Thorac Cardiovasc Surg 2003;126:2090-2092.[Free Full Text]
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Abstract
Introduction
