Granulomatous Lesions

The surface contour of the endolarynx is smooth and symmetrical in inflammatory conditions, with the exception of granulomatous diseases. There is usually preservation of mobility of intralaryngeal structures,

Cervical Part Trachea
figure 4-26 Cuff stenosis of the cervical trachea. A, Coronal tomogram delineates circumferential narrowing of the trachea. B, Anteroposterior high-kilovoltage view illustrates narrowing of the lumen (arrows).

although slight limitation may occur. Chronic granulomatous lesions of the larynx display a diffuse or localized nodular soft-tissue thickening. Frequently, a malignant tumor cannot be differentiated from the granulomatous process, and a biopsy is often mandatory for a definitive diagnosis. Granulomatous processes may extend from the subglottic part of the larynx into the cervical trachea.

Tuberculosis

Larynx. Tuberculosis of the larynx is usually secondary to pulmonary tuberculosis and commonly affects the posterior structures of the larynx. Diffuse swelling or a localized irregular mass may be found, depending on whether the pathologic process is acute, exudative, or chronic productive.45

Tracheobronchial. Tuberculous tracheobronchial stenosis may be caused by extrinsic compression or by adjacent lymphadenopathy or by granulomatous changes within the airway (Figure 4-30). In the hyperplastic stage, tubercles form in the submucosal layer, and ulceration and necrosis of the wall ensues. In the fibrostenotic stage, a smooth stenosis is formed.46 Radiographically, in the hyperplastic stage, the tracheobronchial walls will be nodular and thickened with variable degrees of stenosis (Figure 4-31). Associated lym-phadenopathy may demonstrate rim enhancement with intravenous contrast. There may be parenchymal

figure 4-27 Cuff stenosis of the cervical trachea. A, Coronal tomographic section reveals a localized well-defined cuff stenosis (arrow). B, Lateral view of the cervical trachea demonstrates the stenotic area, chiefly posteriorly (arrow).

figure 4-29 Saber-sheath trachea. Posteroanterior (A) and lateral (B) chest radiographs demonstrate narrowing of the trachea in the coronal plane and widening in the sagittal plane.

Saber Sheath TracheaSaber Sheath Trachea

figure 4-30 Tracheobronchial tuberculosis with lymphadenitis. Computed tomography scan at the level of the carina with soft tissue windows (A) and lung windows (B) reveals an enlarged necrotic low attenuation lowerparatracheal lymph node that contains calcification (A). There is extension of the granulomatous process narrowing the right main bronchus (B).

figure 4-31 Tuberculous bronchial stenosis, hyperplastic stage. Computed tomography scan demonstrates thickening and nodularity of the right main and right upper lobe bronchi associated with right hilar adeno-pathy (A) and cavitation of the right lower lobe (B).

Bronchoscopy Carina Widening

cavitation within the lobes drained by the affected bronchi. In the fibrostenotic stage, the bronchi remain thickened, but have a smooth luminal stenosis (Figure 4-32). If the stenosis is complete, total collapse of a lobe or entire lung will be present.

Broncholithiasis is a late sequela of tuberculosis or histoplasmosis. Rarely, calcified mediastinal nodes will erode into a bronchus, causing obstructive complications such as atelectasis, repeated pneumonia, or bronchiec-tasis. CT is useful to identify the presence and extent of the obstructing bronchial lesion (Figure 4-33). Calcification within the broncholith and associated mediastinal lymph nodes helps to establish the diagnosis.

Fungal Disease

Fungal diseases, such as blastomycosis, candidiasis, histoplasmosis, mucormycosis, rhinosporidiosis, and coccidioidomycosis, produce radiographic intrinsic stenosis of the central airways similar to those described with tuberculosis (Figure 4-34).

figure 4-32 Tuberculous stenosis of the trachea and main bronchi, fibrotic stage. A, Chest radiograph reveals collapse of the left lung. Computed tomography scans reveal diffuse smooth stenosis of the trachea (B) and main bronchi (C). There is collapse of the left lung and a calcific left fibrothorax.

figure 4-32 Tuberculous stenosis of the trachea and main bronchi, fibrotic stage. A, Chest radiograph reveals collapse of the left lung. Computed tomography scans reveal diffuse smooth stenosis of the trachea (B) and main bronchi (C). There is collapse of the left lung and a calcific left fibrothorax.

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