CT of blunt tracheal rupture.

Abstract

19-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. 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.