AJR 2003; 180:1670
© American Roentgen Ray Society
Trauma Cases from Harborview Medical Center |
CT of Blunt Tracheal Rupture
Riyad Karmy-Jones1,
Jeffery Avansino1 and
Eric J. Stern2
1 Department of Surgery, Harborview Medical Center, University of Washington
School of Medicine, Seattle, WA 98104-2499.
2 Department of Radiology, Harborview Medical Center, University of Washington
School of Medicine, 325 Ninth Ave., Box 359728, Seattle, WA 98104-2499.
Received August 21, 2002;
accepted after revision October 3, 2002.
Address correspondence to F. A. Mann.
This is another in the continuing series on radiology in trauma cases from
the Harborview Medical Center. Editors: Fred A. Mann, Eric J. Stern, and Lee
B. Talner.
A19-year-old man presented with mild respiratory distress, subcutaneous
emphysema, and decreased right-sided breath sounds after a high-speed vehicle
crash. A supine chest radiograph showed a large right pneumothorax, right
first rib and clavicle fractures, and pneumomediastinum. A large air leak and
pneumothorax (Fig. 1A)
persisted despite two tube thoracostomies. CT aortography showed a persistent
large right pneumothorax, pneumomediastinum, and a tracheal rupture
(Fig. 1B). Operative
bronchoscopy confirmed the injury, which was repaired primarily.
View larger version (162K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —19-year-old man with blunt tracheal rupture. Anteroposterior
chest radiograph shows large right-sided pneumothorax, pneumomediastinum,
subcutaneous emphysema, and chest wall injuries (arrowheads).
|
|
View larger version (89K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —19-year-old man with blunt tracheal rupture. Axial image from
CT aortogram shows right-sided hydropneumothorax, atelectatic right lung, and
extensive pneumomediastinum. Note defect at junction of trachea and right main
stem bronchus (arrow) indicative of airway laceration. At site of
first rib and clavicular fractures, bronchopleural cutaneous fistula
(arrowhead) is shown as soft-tissue defect.
|
|
Tracheobronchial injuries affect approximately 3% of all patients who
sustain blunt chest trauma. Eighty percent of intrathoracic tracheobronchial
injuries are within 2.5 cm of the carina, most commonly involving the proximal
right main stem bronchus. Eighty percent of these patients die within 2 hr
from associated injuries [1].
Fifty to one hundred percent of patients who sustain blunt tracheobronchial
injuries have major associated injuries, including esophageal perforation in
up to 20%. The most frequent symptoms of all blunt airway injuries are dyspnea
(76–100%) and hoarseness (46%). The most common clinical signs are
subcutaneous emphysema (35–85%) and hemoptysis (14–25%)
[2]. Conventional chest
radiography shows pneumomediastinum in 60% and pneumothorax in up to 70% of
injuries. Other supportive radiographic signs include overdistention of
endotracheal tube cuff, displacement of endotracheal tube, or, in the case of
complete transsection, the fallen lung sign of Kumpe
[3,
4]. A persistent pneumothorax
with a large air leak despite a well-placed chest tube also suggests this
diagnosis, as in our patient. Rarely, a pneumothorax with no air leak at
thoracostomy occurs when mediastinal soft tissue or blood obstructs the
ruptured bronchus.
CT is indicated in the stable patient for the evaluation of possible
associated injuries. An unrevealing CT scan does not obviate bronchoscopy if
intrathoracic tracheal rupture is suspected. The presence of significant air
leak alone is sufficient to mandate bronchoscopy without the need for advanced
imaging.
Primary airway repair is usually possible, except when there is significant
destruction, in which case resection and reanastomosis should be performed. A
small proportion of patients present in a delayed fashion, usually within 4
weeks of injury, with hemoptysis, pneumonitis, or both, complicating an
obstructed airway. Only rarely do patients present with a healed airway injury
years later, typically with dyspnea or the diagnosis of asthma.
References
- Symbas PN, Justicz AG, Ricketts RR. Rupture of the airways from
blunt trauma: treatment of complex injuries. Ann Thorac
Surg 1992;54:177
–183[Abstract]
- Rossbach MM, Johnson SB, Gomez MA, Sako EY, Miller OL, Calhoon JH.
Management of major tracheobronchial ruptures: a 28-year experience.
Ann Thorac Surg
1998;65:182
–186[Abstract/Free Full Text]
- Stark P. Imaging of tracheobronchial injuries. J Thorac
Imaging 1995;10:206
–219[Medline]
- Kumpe DA, Oh KS, Wyman SM. A characteristic pulmonary finding in
unilateral complete bronchial transection. AJR
1970;110:704
–706[Abstract]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
References
