Nontraumatic disruption of the fibrocartilaginous trachea: Causes and clinical outcomes

Background: Nontraumatic disruption of the fibrocartilaginous trachea is rare, and the appropriate management of this condition is not well-characterized. Methods: Retrospective analysis of the clinical features, causes, and outcomes with surgical and nonsurgical management in nine adult patients with nontraumatic fibrocartilaginous tracheal disruption identified by bronchoscopy from January 1, 1975, to December 31, 2004, at a single institution. Results: The most common cause was external beam radiotherapy (RT) in five patients. Other causes included postoperative complications of cervical and superior mediastinal operations in three patients and Aspergillus fumigatus-induced ulcerative tracheobronchitis in one patient post-lung transplantation. Four patients were treated surgically; three because of significant pneumomediastinum and one because the size of the tracheal defect made spontaneous healing seem unlikely. A silicone stent was placed in one patient for concomitant tracheal narrowing, and one patient was treated medically with antifungal agents. The remaining three patients were followed up serially without any intervention. With these treatments, only one patient died as a consequence of tracheal disruption. Repeat bronchoscopies were performed in seven of the remaining eight patients and confirmed healing of the necrotic defect in all. Conclusion: Nontraumatic disruption of the fibrocartilaginous trachea occurs most commonly as a consequence of external beam RT. It can also occur as a complication of cervical and superior mediastinal operations or from A fumigatus-induced ulcerative tracheobronchitis post-lung transplantation. Although surgical treatment has been generally recommended for patients with this condition, patients with contained disruptions without evidence of pneumomediastinum may be managed nonoperatively.