Imaging of Large

Airways Disorders
dr. Yanto Budiman, Sp.Rad, M. Kes

Aprilia Wanda
Lestari Anjani Dewi
Michael
Gita Putri Anjani

Abstract
Objective :
CT thin sections and techniques 2D and 3D increase ability
to detect airways diseases
CT protocols evaluation of dynamic airway disfunction

Conclusion :
Disease of large airways common radiologist must be
familiar with appearances, DD, and clinical implication

Background
Large airways : Trachea, Lobar, and Segmental bronchi (until 23mm)
Recent CT 2D and 3D improve ability to identify diseases or
lesions
Dedicated CT protocols allow the evaluation of dynamic airway
dysfunction :

End-inspiratory CT paired with either dynamic expiratory CT during forceful

exhalation or static end-expiratory CT
Cine CT during coughing

Indication of imaging of the large airways : pulmonary function

test show a discrepancy with clinical presentation
It is important to be familiar with the appearances, DD and clinical
implication of the diseases

Congenital Abnormalities
Tracheal Bronchus
Accessory Cardiac Bronchus
Bronchial Atresia
Tracheoesophageal Fistula
Tracheal Stenosis

Tracheal Bronchus

Tracheal bronchus. Available

from :
http://radiopaedia.org/images/
5967671

Anatomical variant accessory bronchus

originates from supracarinal trachea
2 Type : supranumerary, and displaced
Pig Bronchus when the entire upper lobe
(usually right side) is supplied by this
bronchus
Incidence 0,1-2%
Asymptomatic but impaired drainage
recurrent pneumonia
ETT Atelectasis

Tracheal Bronchus (2)

Chest radiograph of a 20-year-old man showing a right tracheal

bronchus (arrow) and paratracheal mass with the trachea shifted to the
left.
Available from : http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2659830/

Accessory Cardiac Bronchus

Rare variant of tracheobronchial tree , arising
from medial aspect of the bronchus
intermedius or less commonly the right
mainstream bronchus
Incidence 0,09%-0,5%, predilection males
This bronchus progresses conically in an
inferior direction toward the pericardium
Most end blindly, some develop into a
series of small bronchioles ending in vestigial
bronchiolar parenchyma or ventilated lobules
Asymptomatic, abnormal drainage recurrent
pneumonia, hemoptysis

Bronchial Atresia
Congenital obliteration of bronchial
segment, most frequently the left upper
lobe with normal development of
airways proximal and distal to the
lesions,
Usually asymptomatic, if symptomatic
shortness of breath, cough or rarely
infection
Airways distal of the obliteration
characteristics with :
Dilated
Fill with mucus
Bronchocele

Often accompanied with : bronchogenic

cysts, and anomalous branching of the
bronchial tree and vascular structures
Finding in chest radiography and CT:

Central V or Y shaped tubular opacity (finger

glove appearance) surrounded by
hyperlucency to air trapping and
hypoperfusions

Tracheoesophageal Fistula
Abnormal connection between the
trachea and the esophagus
Most occur with esophageal atresia
and are diagnosed in neonates
Feeding difficulty, respiratory
compromise due to repeated
aspiration

TEF without esophageal atresia HType fistulas and may occasionally

be diagnosed later in life
Most TEF in adults tumor,
infections or trauma
Congenital TEF have a high
association with other congenital
anomalies, including cardiovascular,
genitourinary and GIT malformation
Chest radiography may be
suspected if there is an unusual
amount of intestinal distention from
air leaking into GIT

Tracheoesophageal Atresia (2)

Esophageal atresia is closely related
tracheoesophageal atresia can be divided into:
type A: isolated esophageal atresia : 8%
type B: proximal fistula with distal atresia: 1%
type C: proximal atresia with distal fistula: 85%
type D: double fistula with intervening atresia: 1%
type E: isolated fistula (H-type): 4%

 Red arrow points to end of

orogastric tube which is
blocked from entering the
distal esophagus
by the patient's esophageal
atresia. Note the lack of gas in
the abdomen
indicating a fistulous tract does
not connect the trachea to the
distal esophagus

Tracheal Stenosis
Congenital stenosis refers to narrowing of
the tracheal lumen without airway wall
thickening
Most frequently complete or nearcomplete tracheal rings
Severe involving long airway segment
symptomatic early during infancy
Mild asymptomatic and an incidental
finding in adults
Imaging diffuse, segmental or
funnellike progressive airway stenosis
without wall thickening
Long segmental stenosis due to complete
tracheal rings may be associated with a
left pulmonary artery sling
High mortality, treated with
bronchoscopic dilatation and stent
placement, surgical resection of the
involved segment or tracheoplasty

Iatrogenic and Traumatic

Abnormalities

Post intubation stenosis

Tracheal stenosis :
- Congenital
- acquired
Most common ETT, tracheostomy
Ro : focal luminal narrowing
CT : circumferential hour glass apperance

Congenital tracheal stenosis

Post intubation stenosis

Traumatic injury
most frequently : brochii 2,5 cm of carina
Ro: pneumomediastinum and pneumothorax
CT : focal defect or deformity at the site of airway
injury or absence of the airway injury.

Traumatic injury

Foreign body aspiration

Foreign body can be nonopaque or opaque .
Common nonopaque food particle.
Ro : cannot be detected
CT : showing and localizing both opaque and
nonopaque
Dynamic CT sequence :atelectasis and air trapping

Foreign Body

Extrinsic compression
compressed by enlargement of the surrounding
structure.
Congenital vascular anomalies or fibrosing
mediastinitis
Ro and CT : luminal narrowing
Dynamic CT : air trapping and acquired focal
airway collaps.

External compression

Chronic Inflammatory and Infiltrative

Disease

Tracheobronchomalacia
Refers to excessive airway collapse during
expiration
-Weakening the airway cartilage
-Nonweakening the airway cartilage EDAC
Traditional diagnosis : bronchoscopic
Dynamic CT : airway collaps exceeding 70% with
forced expiration

2 classic patern of collaps :

-Cresentic : frown sign
-Circumferential : evenly distributed
Air collaps : accompanied by air trapping
Can make severe respiratory distress
Treatment : CPAP, stent placement, tracheoplasty

Tracheobronchomalacia

Amyloidosis
Characteristic by extracelluler accumulation of
abnormal proteinaceous, insoluble fibrin
Underlying bronchial architecture
Amyloidosis :
-Systemic : common
-Localized : rare

Amyloidosis
Best detected : CT
CT :
-Solitary nodule/multiple nodule protuding intu airway lumen
-Mural calcification
Treatment :
Bronchoscopic techniques :
debridement, laser ablation, ballon dilatation, and stent placement
Local amyloidosis : radiation/chemotherapy

Tracheobronchial amyloidosis

Sarcoidosis
Idiopathic multisystemic granulomatous disease that typically involves
thoracic lymph nodes and the lung parenchyma.
Involve :
-Rare : trachea and main bronchi
-Common : lobar and segmental bronchi

Sarcoidosis stage :
-Early stage
-Late stage
Ro : severe narrowing of trachea and main bronchii
CT :
-subtle airway lesions such as nodular, or smooth airway wall thickening and
narrowing
-Air narrowing result : lymph nodes compressing.
-Traction bronchiectasis : severity of fibrosis.
-Monitoring disease progression

Sarcoidosis

Granulomatosis with Polyangiitis

Antineutrophil cytoplasmic antibodyassociated vasculitis.
Affects
small
vessels.
Manifestation:
involvement.

and

medium-sized

tracheobronchial tree

Airway wall thickening,

reversible stenosis.

fixed

or

Iregular calcifications of the tracheal

cartilage rings.
Chest Radiography: smooth stenosis of
the airways and pulmonary opacities.
CT: smooth or nodular thickening of
the tracheobronchial wall -> single or
multiple stenosis

Relapsing Polychondritis
Rare
autoimmune
disorder
causing recurrent inflammation
and subsequent destruction of
cartilage in the ear, joints,
airways and nose.
Inflammation and destruction ->
loss of supportive function ->
excessive
collapse
of
the
airways during expiration.
Stenosis and mural thickening.
CT: diffuse smooth thickening of
the
tracheobronchial
wall,
excessive
collapsibility
associated with air trapping.
Calcifications,
stenosis
and
obstructive bronchiectasis.
Poor prognosis.

Tracheobronchomegaly
Mounier-Kuhn syndrome
Congenital presidposition combined
with acquired factors such as
infections and chronic irritation from
smoking.
Dilatation of the trachea and main
bronchi results from atrophy of
smooth muscle and elastic tissue.
Radiography: tracheobronchomegaly
CT: increased diameter and extent of
airway dilatation, multiple small
diverticula and bronchiectasis.
Women: coronal -> 21mm, sagittal ->
23mm.
Men: coronal -> 25mm, sagittal ->
27mm.

Tracheobronchopathia
Osteochondroplastica
Rare
idiopathic
condition,
causing
thickening
of
the
tracheal rings.
Affects trachea and cartilaginous
components.
Chest
radiography:
normal,
tracheal scalloping or irregular
asymmetric airway stenosis.
CT: thickened cartilage rings with
irregular
calcifications
and
multiple nodules.

Bronchial Anthracofibrosis
Focal luminal narrowing of the
bronchi with darkened bronchial
mucosa in patients without
exposure to coal dust or
cigarette smoking.
Causes: tuberculosis, chronic
exposure to biomass smoke.
Nonspecific symptoms: cough,
increased sputum production,
dyspnea and recurrent infection.
Chest
radiography:
consolidations or atelectasis.
CT: thickening of the bronchial
walls and peribronchial soft
tissues.
Lymph nodes often enlarged and
may be calcified.
Most common in lung distal.
Refer
to:
bronchogenic

Bronchilithiasis
Calcified material within the bronchial
lumen.
Calcified lymph node, typically caused
by necrotizing granulomatous
lymphangitis from histoplamosis or
tuberculosis.
The disappearance of or a change in the
position of previously seen calcified
opacity on chest radiography suggests
broncholithiasis.
CT: more sensitive.

Infection

 Inflammatory response focal or diffuse

airway wall thickening and occasionally in
luminal narrowing

Viral Infection
Common: viral croup
Mucosal swelling seal like barking cough, stridor,
hoarseness
Chest radiography indication: clinically uncertain
steeple sign without epiglotis involvement

Bacterial infection
Bacterial tracheitis
More severe: membranous tracheal secretion
Lower respiration tract involvement: crackles, wheezing,
pneumonia
Chest radiograph: narrowing upper trachea (irregular) + linear
oppacities within the tracheal lumen

 Endobronchial tuberculosis
Most common: distal trachea and proximal
bronchi
Chest radiography: luminal narrowing or
atelectasis, wall thickening
CT: active and fibrotic stages,
lymphadenopathy, bronchiectasis, parenchymal
inflammatory changes, severe stenosis
(bronchoscopic dilatation and stenting)

 Rhinoscleroma (Klebsiella rhinoscleromatis)

Chronic nasal obstruction, rhinorrhea, epistaxis,
absence of the uvula, hebra nose
Dyspnea and stridor airway lesions
(granulomatous nodules, dense fibrotic
stenosis)
Chest radiography: nodular irregularities/diffuse
narrowing of the large airways
CT: irregular, nodular, concentric luminal
narrowing, wall thickening of soft tissue without
calcification. Sometimes mucosa shows crypt or
sinuslike lesions

Fungal Infection
Aspergillus, coccidioides, candida, cryptococcus,
histoplasma
Underlying immune system condition

 Aspergillus:
Allergic bronchopulmonary: mucus
production, ciliary function mucoid
impaction, mucosal invasion (-)
Chest radiography: CT: intraluminal nodules or masses of soft
tissue, wall thickening, stenosis, and
occasionaly intramural air, bronchiectasis,
lymphadenopathy, fingerlike opacities of soft
tissue
Definite diagnosis: bronchoscopy

Neoplasms

Benign Neoplasms
<10% of airway neoplasms
Hamartoma
Tracheobronchial papillomatosis (human
papillomavirus):
Cavitated nodule
laryngx trachea, bronchi, lung

Other: leiomyomas, lipomas, chondromas,

neurogenic tumors

Malignant Neoplasms
>2 cm flat or polypoid lesions with lobulated or irregular
border
Most common: direct invasion
Less common: metastase
Bronchi: bronchial squamous cell carcinoma, small cell
carcinoma, carcinoid tumor

 Chest radiography: focal luminal narrowing

from a soft tissue opacity or sigs of airway
obstruction (atelectasis and recurrent
pneumonia)
CT: intraluminal mass of soft tissue, may
invade surrounding structures
Hamartoma: fat and cartilaginous tissue within
a lesion
Lipoma and liposarcoma: fat containing lesions
Carcinoid tumor: calcification and marked
homogenous contrast enhancement

Definitive diagnosis: biopsy

Conclusion
Evaluation of large airways: lumen, wall structure, wall
thickness, lung parenchyma, and surrounding tissues
Distint pattern of dimensional and structural