PMC7238787_01
Bronchoscopy. (A) Vocal cords of normal aspect. (B and C) Superior trachea with irregular nodular lesions over cartilaginous rings, with greater profusion toward the left side, covered by intact mucosa. (D) Middle third of the trachea with similar lesions and mild decrease of tracheal lumen. (E) Inferior third of the trachea with greater profusion of lesions near the carina, sparing completely the posterior wall. (F) Right main bronchus with similar nodular lesions in the lateral wall.
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Bronchoscopy was performed and multiple nodules were found from the subglottic area to the main bronchi, distributed in the anterior and lateral walls with "cobblestone throat" appearance (Figure 1).
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Thoracic axial computed tomography scan. Loss of normal tracheal morphology with soft tissue nodule (65 HU) on the right tracheal wall, without significant stenosis.
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Multiple soft tissue nodules were found in the trachea, without stenosis (Figure 2).
PMC7238787_03
(A) Thoracic coronal computed tomography maximal intensity projection (CT MIP) reconstruction. Multiple endobronchial nodules are shown, along with reduced lung volumes. (B) Thoracic coronal CT MIP reconstruction. Irregular tracheal walls with moderate stenosis in the middle third. (C) Virtual bronchoscopy showing endotracheal nodular surface with rock garden appearance.
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Chest CT was performed finding multiple endotracheal nodules on the right lung, along with reduced lung volume (Figure 3A). On maximal intensity projection reconstruction, irregular tracheal walls with moderate stenosis in the middle third were found (Figure 3B). Virtual bronchoscopy showed a nodular surface with "rock garden" findings (Figure 3C).
Thoracic axial dynamic computed tomography scan. (A) Demonstrating tracheal stenosis during inspiration with an area of 1.5 cm2 that reduces to (B) an area of 0.8 cm2 during expiration. (C) Compared with the superior third of the trachea with an area of 3.6 cm2 during inspiration and (D) 3.2 cm2 during expiration, which gives a stenosis of 75%.
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A dynamic chest CT was performed showing tracheal stenosis during inspiration with an area of 1.5 cm2 (Figure 4A), which decreased to 0.8 cm2 (Figure 4C) during expiration compared with control (superior third of the trachea) with areas of 3.6 cm2 (Figure 4B) and 3.2 cm2 (Figure 4D), respectively.
Bronchoscopy. (A and B) Middle third of the trachea where the deformity of the structure can be seen secondary to the nodules found on the anterolateral walls. (C-E) Inferior third of the trachea with random distribution of nodules that do not cause tracheal obstruction. (F) Main bronchi compromised by similar lesions.
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Bronchoscopy (Figure 5) found solid nodular lesions on the cartilaginous rings, with altered tracheal structure, especially in the superior and middle third throughout the main bronchi.
PMC7238787_04
(A) Thoracic coronal computed tomography (CT) with a mild beaded appearance of the trachea with no airway stenosis. (B) Thoracic axial CT scan showing mild thickening of the anterolateral walls of the trachea with nodules, which are calcified. (C and D) Bronchoscopy showing diffuse submucosal nodules with an intact overlying mucosa, compromising the anterolateral walls and extending to the main bronchi. Observe the intact membranous trachea.
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Tracheal mucosa was normal (Figure 6C and D).
Biopsy taken during bronchoscopy. (A-C) Respiratory epithelium with submucosal osseous nodules and hematopoietic tissue formation. (D) Ciliated respiratory epithelium, global cell, and transition area between osseous and cartilaginous tissue.
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Biopsies were performed and TO was confirmed (Figure 7).
PMC7238787_05
(A) Thoracic axial computed tomography (CT) scan with moderate nodular thickening of the anterior and lateral walls of the trachea of heterogeneous density and scalloped edges. Note the absence of compromise of the posterior wall of the trachea. (B) Thoracic axial CT scan with multiple calcified endotracheal nodules (170 HU). (C) Thoracic coronal CT scan maximal intensity projection reconstruction showing endobronchial nodules and beaded appearance of the trachea. (D) Virtual bronchoscopy showing multiple nodules giving a cobblestone appearance with compromise extending to the level of the tracheal carina, as shown by the axial, coronal, and sagittal reconstructions at the right.
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CT was performed in which metastasis was ruled out and TO was suspected. Chest axial CT scan shows thickening of the anterior and lateral tracheal walls of heterogeneous density and scalloped edges, along with calcified nodules (Figure 8A and B). On maximal intensity projection reconstruction, multiple endobronchial nodules with "beaded" appearance of the trachea were found (Figure 8C). In the virtual bronchoscopy, multiple nodules with "cobblestone throat" appearance were seen throughout the carina (Figure 8D).