Diseases of the Trachea and Airway

Tracheal and airway tumors are very rare and often initially misdiagnosed (Figure 3). The most common primary tracheal tumors are squamous cell carcinoma and adenoid cystic carcinoma. Patients often have cough, wheezing, stridor, and hemoptysis (coughing up blood). Evaluation includes a CT scan and bronchoscopy, during which the exact location and character of the tumor is determined. Bronchoscopy can be "flexible" (where the bronchoscope can bend and uses video enhancement of the image) or "rigid" (where a larger, metal bronchoscope allows the use of larger instruments). Tumors that are too extensive to be completely removed by surgery are often debulked or ablated using mechanical, laser, or other energy-employing techniques such as argon beam or cryo (cold) therapy.

Resectable tracheal tumors are most often treated with a tracheal resection and reconstruction (Figure 4). Most often this operation is performed through the neck, although if the tumor is farther down the trachea, it can be done through an incision in the breastbone (sternotomy) or the right chest (thoracotomy) (Figure 5). Patients may require postoperative radiotherapy and/or chemotherapy for malignant tumors.

A tracheoesophageal fistula (TEF) is an abnormal connection between the trachea and esophagus. These are usually caused by complications of intubation, trauma, or operations such as esophagectomy or laryngectomy. Patients can become very ill due to infected fluid from the esophagus contaminating the lungs. After the associated pneumonia and poor nutritional state are improved, treatment requires a tracheal resection and reconstruction (Figure 4) as well as repair of the esophagus. The goal of this operation is for the patient to breathe and eat comfortably again.

Tracheomalacia is a weakness in the membranous (back) trachea and change in the shape of the cartilaginous (front) trachea (Figure 6). When patients with tracheomalacia exhale, the membranous trachea bows towards the cartilaginous trachea, obstructing the airway. This abnormality often extends to the bilateral mainstem bronchi, the smaller airways that split off from the trachea, in which case it is called tracheobronchomalacia.

Tracheomalacia and tracheobronchomalacia are often diagnosed after a long evaluation for shortness of breath, cough, or multiple pulmonary infections. Evaluation starts with a CT scan with images taken during both inhalation and exhalation, and bronchoscopy. The Interventional Pulmonology team often places temporary Y stents to keep the airway open and determine whether surgery is likely to improve symptoms more permanently. The Y stents cannot be left in place for long periods of time.

In select patients, this condition can be treated with tracheoplasty or tracheobronchoplasty, performed through the right chest (Figure 5). In this operation, a Y-shaped mesh is sewn to the back of the trachea and mainstem bronchi to reinforce the membranous wall and prevent collapse of the airway during exhalation or cough (Figure 6 and Figure 7). Patients often have great improvement in their breathing and functional status after this operation.