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University of California, San Diego VA San Diego Healthcare System San Diego, CA 92162
I would like to comment on a statement made on page 1279 of the May issue in the otherwise excellent article by Chen et al., "Using CT to Diagnose Tracheal Rupture" [1]. The authors assert that herniation of the endotracheal tube balloon outside the tracheal wall has not, to their knowledge, been described as a specific sign of tracheal injury.
I would like to bring to the attention of the authors the comprehensive review, "Imaging of Tracheobronchial Injuries" [2]. Figure 18 on page 215 of that article displays just such a case of herniation of the endotracheal tube cuff through a longitudinal rent in the posterior membranous wall of the trachea. This article was not cited by Chen et al. [1] in their review of the literature.
I hope that this comment will be of interest to the readers of the AJR.
References
University of Maryland Medical Center Baltimore, MD 21201
We welcome Dr. Stark's letter and acknowledge his keen interest in and contributions to the radiology of thoracic trauma. Stark is correct in noting that his article, "Imaging of Tracheobronchial Injuries" [1], illustrates a CT study of tracheal rupture through the membranous portion with posterior herniation of a distended endotracheal balloon. The comment in our article [2] is perhaps somewhat misleading in that we were attempting to refer to cases of focal balloon herniation through small tears that result in appearances such as the "Mickey Mouse" or dumbbell signs that, again to our knowledge, have not been described on CT as specific findings of full-thickness tracheal injury.
Rollins and Tocino [3] first described and illustrated the CT finding of endotracheal balloon herniation as a sign of full-thickness tracheal tear in 1987. Dr. Stark's review article on tracheobronchial injury is excellent and well referenced but does not cite this important previous article from the AJR.
Even with the best of intentions, important references are not always included in new work. This may be related to the intensity of the search, the availability of reference material when needed, applicability of the reference to the particular topic, or the availability of other references that are similar. We are not certain why Dr. Stark's superb review article was not included in our article, which was very thoroughly researched, but we hope he receives appropriate recognition through this correspondence.
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