Tracheal Rupture

Tracheobronchial injury after blunt or penetrating traumatic chest injury is rare, occurring in less than 2% of cases. The majority of intrathoracic tracheobronchial injuries are within 2.5 cm of the carina and most commonly affect the proximal right main stem bronchus.

Tracheal rupture makes up about 1/4 of all tracheobronchial injuries, and is associated with high morbidity and mortality from ventilatory failure, infection (mediastinitis, sepsis), and intermediate- and long-term complications (airway stenosis, recurrent pulmonary infections, bronchiectasis, and permanent pulmonary function impairment).

Clinical and imaging manifestations are subtle and nonspecific, and can result in delayed or missed diagnosis.

Deep cervical emphysema, pneumomediastinum, and paratracheal gas are seen in the vast majority of cases. The tracheal wall injury can sometimes be directly visualized on CT as a tracheal wall defect of discontinuity. Focal tracheal wall deformity or tracheal ring fracture can be more subtle indications of the location of injury.

In the intubated patient, additional signs of tracheal injury include overdistended, extraluminal, or herniated endotracheal tube balloon cuffs.

Pneumothorax and and pneumoretroperitoneum can be secondary findings, and a persistent pneumothorax despite a well-placed thoracostomy tube suggests a diagnosis of tracheobronchial injury.

Special thanks to Dr. Hansel Otero for the case.

References

• Chen JD, Shanmuganathan K, Mirvis SE, Killeen KL, Dutton RP. Using CT to diagnose tracheal rupture. Am J Roentgenol. 2001 May;176(5):1273-80.
• Karmy-Jones R, Avansino J, Stern EJ. CT of blunt tracheal rupture. AJR Am J Roentgenol. 2003 Jun;180(6):1670.