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Tracheal diverticulum: a rare finding in a patient with worsening chronic cough.

Abstract

Acquired tracheal diverticulum is a rare clinical entity with only limited reports in the literature. We report a case of a tracheal diverticulum that was identified as part of a work-up for a worsening cough. In this case the diverticulum was observed 2 years after surgical management of a retropharyngeal abscess. It was felt that pooling of secretions in the acquired pouch was a contributing factor in the exacerbation of the patient's chronic cough. Because of the patient's extensive comorbidities, observation and serial computed tomography scans were recommended.

Introduction

Tracheal diverticulum, also referred to as tracheocele, is typically discovered as an incidental finding on a radiograph, on endoscopy, or during a postmortem examination. (1) It is a rare clinical entity with only limited reports in the literature.

Tracheal diverticula can be congenital or acquired. The congenital type is typically small and narrow-mouthed while the acquired type is larger and wide-mouthed. Mounier-Kuhn syndrome, a rare, most likely congenital, disorder can be mistaken for tracheal diverticulum because it involves dilatation of the trachea and main stem bronchi, with folds of redundant mucosa and fibromuscular tissue that resemble diverticula. (2,3) Acquired diverticula are thought to be outpouchings that occur at weak points in the posterior wall of the trachea in response to increased intraluminal pressure, such as occurs during a cough.

This article describes the discovery of an acquired tracheal diverticulum that was observed 2 years after surgical management of a retropharyngeal abscess.

Case report

An 81-year-old man, a dairy farmer, presented to his primary care physician with a 2-year history of a persistent cough. The cough had been present since he had developed a retropharyngeal abscess that required intubation for airway control and surgical drainage. He had recovered without complication from that procedure, with the exception of the persistent cough and some intermittent swallowing difficulty.

The patient described the frequency and severity of his cough as waxing and waning, and generally nonproductive; he denied any hemoptysis. The cough was typically worse at night when the patient was in bed and in the morning when he first got out of bed. He did report significant gastroesophageal reflux disease (GERD) symptoms and postnasal drip. His medical and surgical histories were significant for hypertension, coronary heart disease with stable exertion angina, coronary artery bypass graft, hyperlipidemia, and mild anemia. He was not taking an angiotensin-converting enzyme inhibitor or any other medication associated with cough.

Computed tomography (CT) of the patient's neck and chest revealed an "abnormal, sac-like collection of air along the right lateral posterior aspect of the trachea, at the level of T2 and T3." The 1.5 x 1.4-cm tracheal diverticulum was located on the right posterior, lateral to the distal trachea (figure). CT also showed findings consistent with interstitial fibrosis and no evidence of retropharyngeal abscess or prevertebral thickening. (The patient's CT scans that had been obtained 2 years earlier to evaluate his retropharyngeal abscess were reviewed and did not reveal any evidence of a tracheal diverticulum at that time.)

Based on these findings, the patient was referred to our pulmonology and otolaryngology departments at Fletcher Allen Health Care, Burlington, Vt. After complete evaluation and consultation, it was determined that the differential diagnosis for his chronic cough included untreated GERD and postnasal drip, usual interstitial pneumonia, and chronic hypersensitivity pneumonitis with traction bronchiectasis. Although the symptoms related to GERD and postnasal drip completely resolved on maximal medical treatment with proton pump inhibitors and steroid nasal spray, his cough remained unchanged.

The lack of sputum production spoke against bronchiectasis being the cause for this patient's cough, and the fact that he had chronic hypersensitivity pneumonitis with fibrosis for > 10 years and symptoms for only 2 years argued against either of those conditions being the primary problem. It was agreed that, despite the multiple potential sources of persistent cough, the tracheal diverticulum was a likely contributor to the problem.

The patient's cough was refractory to all attempts at medical intervention, including inhalers and improved control of his acid reflux. His case was reviewed in consultation with a group of cardiothoracic surgeons at a nearby academic hospital, none of whom had any experience with this particular finding. They recommended a conservative approach of observation and serial CT scans because of the patient's extensive comorbidities. The patient has been lost to follow-up.

Discussion

Tracheal diverticula have been reported to be associated with chronic cough, recurrent nerve paralysis, and/or cervical neck swelling. (2,4,5) They have also been reported to cause difficult endotracheal intubation with associated pneumomediastinum, as well as ventilation difficulty. (6,7)

The present case demonstrates the identification of a tracheal diverticulum on a CT scan obtained 2 years after surgical drainage of a retropharyngeal abscess. It is unclear whether the infection or endotracheal intubation that took place during the management of the patient's retropharyngeal abscess was the cause. It seems possible that the intubation weakened the posterior trachea, leading to the development of the diverticulum, and that coughing further contributed to its development. Pooling of secretions in the acquired pouch would explain the exacerbation of the patient's cough when he was lying down and when he first awoke in the morning.

[FIGURE OMITTED]

The choice of treatment for tracheal diverticulum is based on the patient's age and comorbidities. Surgical resection is typically reserved for the young, while conservative observation and symptomatic treatment are used in the elderly. (1)

References

(1.) Davies R. Difficult tracheal intubation secondary to a tracheal diverticulum and a 90 degree deviation in the trachea. Anesthesia 2000;55(9):923-5.

(2.) Lazzarini-de-Oliveira LC, Costa de Barros Franco CA, Gomes de Salles CL, de Oliveira AC Jr. A 38-year-old man with tracheomegaly, tracheal diverticulosis, and brochiectasis. Chest 2001;120 (3):1018-20.

(3.) Caversaccio MD, Becker M, Zbaren P. Tracheal diverticulum presenting with recurrent laryngeal nerve paralysis. Ann Otol Rhinol Laryngol 1998;107(4):362-4.

(4.) Infante M, Mattavelli F, Valente M, et al. Tracheal diverticulum: A rare cause and consequence of chronic cough. Eur J Surg 1994; 160(5):315-16.

(5.) Mathur NN, Sardana P, Singh VP, Bais AS. Adult tracheocele with large cervical presentation. J Laryngol Otol 1999;113(4);364-5.

(6.) Moller GM, ten Berge EJ, Stassen CM. Tracheocele: A rare cause of difficult endotracheal intubation and subsequent pnuemomediastinum. Eur Respir J 1994;7(7):1376-7.

(7.) Dinner M, Ward R, Yun E. Ventilation difficulty secondary to a tracheal diverticulum. Anesthesiology 1992;77(3):586-7.

Gregory P. Danielson, MD; Veronika Jedlovszky, MD; Gary P. Landrigan, MD

From the Division of Otoloaryngology--Head and Neck Surgery, Department of Surgery, University of Vermont College of Medicine, Burlington (Dr. Danielson and Dr. Landrigan), and the Department of Pulmonary Medicine, North Country Hospital, Newport, Vt. (Dr. Jedlovszky).

Corresponding author: Gary P. Landrigan, MD, Department of Otolaryngology-Head and Neck Surgery, West Pavilion, Level 4, 111 Colchester Ave., Burlington, VT 05401. Phone: (802) 847-4535; fax: (802) 847-8198; e-mail: gary.landrigan@vtmednet.org
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Article Details
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Title Annotation:ORIGINAL ARTICLE
Author:Danielson, Gregory P.; Jedlovszky, Veronika; Landrigan, Gary P.
Publication:Ear, Nose and Throat Journal
Article Type:Clinical report
Geographic Code:1USA
Date:Aug 1, 2008
Words:1150
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