Parenchymal, cystic, and vascular lesions may obstruct the trachea by compression. Chronic compression may result in malacic changes in the deformed cartilages. The problem may, therefore, be dual. The lesion initially narrows the trachea by compression. If severe malacia results, the trachea may collapse following removal of the support which was provided by the mass lesion.
A thyroid goiter may displace and deform the cervical or intrathoracic trachea markedly, over a short or long segment (Figure 15-6). The narrowing may be symmetrical, but more frequently is eccentric. In large goiters that have a major substernal or intrathoracic component, tracheal deformity and obstruction is more likely to be caused by those goiters that pass into the thorax laterally and posteriorly ("posterior descending goiter"), rather than by strictly anterior substernal goiters. The latter more often lie anterior to the great vessels and hence are less likely to compress the trachea seriously. Particularly in aged patients, where only a small portion of the trachea lies above the sternal notch, a goiter may be almost entirely intrathoracic and not be visible or palpable in the neck. In a series of 80 patients with intrathoracic goiters, reviewed by Katlic and colleagues, dysphagia was present in 33%, dyspnea in 28%, stridor in 16%, hoarseness in 13%, wheeze in 9%, and cough in 8%.9 A cervical mass was the most common finding (69%). In one-third of the patients, the trachea was markedly deviated. Most lesions are multinodular goiters or follicular adenomas, with a rare incidence of Hashimoto's thyroiditis. Occult carcinoma is encountered in 2 to 3% of substernal goiters, at most.10
The treatment of obstructive goiter, whether cervical or intrathoracic, is surgical. There is little evidence that prolonged thyroid suppression (used in 59% of our series), radioiodine, or propylthiouracil effect regression of goiters and relief of compression. Since goiters may recur over a period of many years, complete removal of the affected lobe or lobes is advisable.
figure 15-3 Imaging in tracheomalacia. A, Fluoroscopy in a 57-year-old man with severely symptomatic malacia of the intrathoracic trachea and main bronchi. Oblique spot films of the trachea, inspiratory on left and expiratory on right. Note that the collapse is intrathoracic. B, Oblique tomo-grams, inspiratory on left and expiratory on right, in same patient of A.
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