Tracheobronchopathia osteochondroplastica and difficult intubation: case report and perioperative recommendations for anesthesiologists

Clinicopathological Features and Management Principles of Tracheobronchopathia Osteochondroplastica - A Scoping Review

Tracheobronchopathia osteochondroplastica (TO) is an orphan disease of the tracheobronchial tree without any known etiological attributes. There are several case reports published on this condition, yet the available information about the TO is discrete and of little clinical value. This scoping review is the first large-scale review on TO that collates individual patient data from the published case reports and descriptively analyses the clinicopathological features of this unique condition along with its management approaches and therapeutic outcomes. The objective was to synthesize comprehensive literature review on TO that can aid clinical practice and further research. An electronic search conducted in five large databases, including PubMed, EMBASE, CINAHL, CENTRAL, and Web of Science, for the published articles of TO yielded 1072 items. After screening, the individual patient data of 371 TO cases from 228 eligible articles were included and analysed in this scoping review.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03998-6.

Tracheobronchopathia osteochondroplastica: a rare cause of tracheal tube cuff leak

We present the case of a patient with the rare disorder tracheobronchopathia osteochondroplastica who underwent laparoscopic cholecystectomy. After induction of general anaesthesia, we faced difficulties passing the tracheal tube beyond the vocal cords despite bronchoscopic assistance. With a smaller tube, and by using rotating movements, we managed to successfully intubate the trachea. Because of the irregular tracheal surface, however, ventilation was challenging due to a massive cuff leak. Repeated repositioning did not improve this leak. Only cuff overinflation led to adequate ventilation, though we were cognisant of the increased risk of tracheal wall injury with this approach. After completion of the surgery, the patient's trachea was extubated without complication. This case showed that even with good preparation, intra-operative problems can occur with abnormal subglottic airway anatomy. In some circumstances, these problems can only be solved by compromise. There are no professional consensus or guidelines that can be followed as guiding references for such a case, which can lead to indecisiveness.

The Rocks Valley: Tracheopathia Osteochondroplastica: A Case Report

Tracheopathia Osteochondroplastica is a rare benign tracheobronchial condition. Its unspecific symptoms and high clinical threshold for diagnosis make the condition an incidental diagnosis. We report an incidental tracheopathia osteochondplastica in 66 years old male patient with suspected thyroid malignancy.

Tracheobronchopathia osteochondroplastica: clinical, bronchoscopic, and comorbid features in a case series

Background

Tracheobronchopathia osteochondroplastica (TO) is a rare condition of unknown etiology. TO is characterized by submucosal nodules, with or without calcifications, protruding in the anterolateral walls of the trachea and proximal bronchi. The objective of this study was to describe TO features and associated comorbidities in a series of patients.

Methods

Patients suffering from TO were retrospectively included by investigators from the Groupe d’Endoscopie Thoracique et Interventionnelle Francophone (GETIF). Demographic, clinical, comorbidities, bronchoscopic, functional, and radiological characteristics, and outcomes were recorded and analyzed.

Results

Thirty-six patients were included (69% male with a mean of 65 ± 12 years). Chronic symptoms were described by 81% of patients including cough (74%) and dyspnea on exertion (74%). TO was associated with COPD in 19% of the cases and gastroesophageal reflux disease in 6%. A mild to severe airflow obstruction was present in 55% of the cases. CT scan showed tracheal submucosal nodules in 93% of patients and tracheal stenosis in 17%. Bronchoscopy identified TO lesions in the trachea in 65% of the cases, and 66% of them were scattered. A bronchoscopic reevaluation was performed in 7 cases, 9 ± 14 months [1–56] after initial diagnosis, and showed the stability of lesions in all cases. Three patients underwent interventional bronchoscopic treatment.

Conclusion

The diagnosis of TO relies on typical bronchoscopic findings and can be evoked on a CT scan. Histologic diagnosis can be useful in atypical cases for differential diagnosis. Given its low consequences in terms of symptoms, lung functions, and evolution, no treatment is usually required.

Tracheobronchopathia Osteochondroplastica-Clinical, Radiological, and Endoscopic Correlation: Case Series and Literature Review

Tracheobronchopathia osteochondroplastica (TO) is a rare idiopathic and benign disease that is often underdiagnosed. TO is characterized by multiple submucosal cartilaginous and osseous tracheobronchial nodules that spare the posterior wall. It usually affects the elderly, developing when the person is around 60 years old without gender preference and has a reported incidence of 0.11%. TO can be symptomatic and should be considered in patients with chronic cough, dyspnea, and recurrent pulmonary infections. Diagnosis is usually incidental by computed tomography or bronchoscopy, the latter being the gold standard diagnostic test for TO. Many thoracic imagers are not well acquainted with TO; thus, these patients are often underdiagnosed or misdiagnosed. We came across 5 patients in our institution who were incidentally diagnosed with TO, inspiring us to review the available literature on this disease. A total of 33 patients diagnosed with TO between 2009 and 2019 were identified by our retrospective review. Clinical and imaging data were collected on these patients. We also included the clinical, radiological, and endoscopic data of our 5 cases. TO should be considered in patients with chronic cough, dyspnea, and recurrent pulmonary infections. Our experience is that both computed tomography and bronchoscopy can be used to make a reliable diagnosis. It is crucial for physicians, especially radiologists and pulmonologists, to be aware of the existence of TO in order to ensure proper diagnosis.

Intubation Technique in a Patient with Tracheobronchopathia Osteochondroplastica

BACKGROUND Tracheobronchopathia osteochondroplastica (TO) is a rare disorder characterized by cartilaginous or ossified submucosal nodules of unknown etiology that project into the tracheobronchial lumen. TO is often accompanied by endotracheal stenosis from cartilage proliferation and is often detected by difficult endotracheal intubation incidence. CASE REPORT Here we report the case of a patient (67-year-old man) with TO scheduled to undergo robot-assisted total prostatectomy for prostate cancer. The tracheal lumen was especially narrow at an area 1 cm below the glottis, with the smallest lumen diameter being 9 mm. After rapid induction, the bronchoscope passed through the stenosed region, and a 6.5-mm spiral endotracheal tube (ETT) was inserted with bronchoscopic assistance. However, because of resistance, the spiral ETT could not pass through the stenosed area. After changing to a 6.5-mm normal ETT, intubation was successfully performed with gentle rotation. Owing to the rotation, the tip entered and gained access to the gap between nodules. With use of a bronchoscope, we confirmed that the tip of the ETT was advanced 10 cm from the glottis, where the site of maximum stenosis was not covered by the tube cuff, and where the tip did not cross the bifurcation. After surgery, no bleeding or edema was found on bronchoscopy. CONCLUSIONS In patients with TO, it is important to assess the airway condition and prepare for difficult intubation. In this case, tracheal intubation was performed with rotation using a bronchoscope and normal ETT.

Study and reflection on anesthesia for tracheobronchopathia osteochondroplastica

Tracheobronchopathia osteochondroplastica (TO) is a rare disease that may cause unexpected difficult intubation. There is no available consensus on the management of difficult intubation that is associated with TO. A 45-year-old woman was scheduled for modified radical mastoidectomy, canaloplasty, and tympanoplasty under general anesthesia. We encountered significant resistance during tracheal intubation, although the laryngeal view was normal with the video laryngoscope. A fiberoptic bronchoscope was then used to facilitate intubation, and we noted that the trachea was obviously narrowed due to cartilaginous ring hypertrophy. The tracheal tube was fully lubricated with tetracaine gel, and smoothly inserted into the trachea. After the operation, bronchoscopy and a computed tomography (CT) scan were performed to confirm the diagnosis of TO. Fiberoptic bronchoscopy-assisted tracheal intubation is safe and effective choice for the patients in whom subglottic intubation is difficult. CT scan and bronchoscopy might be helpful for preoperative airway assessment. Identifying patients with TO is important to avoid unexpected tracheal intubation impediment. Assessment of the subglottic airway should also be taken seriously.

Tracheobronchopathia osteochondroplastica: rare but not to be forgotten

We report a case of a 59-year-old male with a one-month history of pleuritic chest pain who was diagnosed with tracheobronchopathia osteochondroplastica (TO). TO is a rare benign condition characterized by protruding submucosal nodules into the tracheobronchial lumen. The disease is generally asymptomatic, with rare cases of progressive nodularity, cough, dyspnoea, and haemoptysis. Diagnosis can be made via bronchoscopic visualization of bony and cartilaginous nodules on tracheal walls. Although generally benign, the rarity of this condition makes diagnosis difficult even for trained pulmonologists and frequently predisposes patients to unnecessary invasive diagnostic testing and improper management of symptoms and contributing co-morbid conditions. We present this case to increase physician and patient awareness about this disease to help improve diagnostic strategy and knowledge of disease manifestations and potential complications.

Difficult intubation in an asymptomatic patient with tracheobronchopathia osteochondroplastica

Tracheobronchopathia osteochondroplastica (TO) is a rare, benign, slowly progressive disease of unknown aetiology. It is characterized by numerous sessile, cartilaginous, or osseous submucosal nodules distributed throughout the anterolateral walls of the trachea and projecting into the laryngotracheobronchial lumen. The diagnosis is usually incidental with distinct bronchoscopic or computed tomography (CT) scan findings. We have identified a case of asymptomatic TO through fibreoptic bronchoscopy and biopsy after having a difficult intubation for elective prostate surgery.

Tracheobronchopathia osteochondroplastica: awareness is the key for diagnosis and management

Tracheobronchopathia osteochondroplastica is a rare airway disease of unknown aetiology. Due to overlapping symptomology and lack of awareness, the condition is often missed resulting in unnecessary medical or surgical treatment. A male patient presented with a long-standing history of hoarseness and had earlier received treatment for bronchial asthma and tuberculosis. On evaluation, he had typical submucosal calcified nodules distributed throughout the trachea sparing the posterior membranous part. Although the biopsy confirmed the diagnosis of tracheobronchopathia osteochondroplastica in our case, histopathological examination is not always needed to make this diagnosis. Our patient has been kept under conservative management and is having non-progression of disease at 1-year follow-up. After having reviewed the literature related to pathophysiology and management of tracheobronchopathia osteochondroplastica, we emphasise on the fact that the treating physicians' awareness about this condition is the key to its diagnosis and management.

Right Upper Lobe Shadow and Tracheobronchopathia Osteochondroplastica Confined to Right Main Bronchus: A Case Report and Literature Review

Tracheobronchopathia osteochondroplastica (TO) is a well documented benign entity of endoscopic interest. We describe a case of 76-year-old patient who presented with fever, cough, purulent sputum during the past four days, and presence of an ovoid shadow in right upper zone of his chest X-ray. Medical history included diagnosis of colon diverticuli identified by colonoscopy 3 months ago. Chest CT revealed a compact elongated lesion containing air-bronchogram stripes. Bronchoscopy showed normal upper airways and trachea but presence of unequal sized mucosal nodules, protruding into the lumen, along the entire length of the right main bronchial mucosa. No other abnormal findings were detected. Moreover, brushing and washing smears from the apical segment of right upper lobe (RUL), where the compact lesion was located, were negative for malignancy. Biopsy from the mucosal nodules of right main bronchus showed presence of cartilaginous tissue in continuity through thin pedicles with submucosal cartilage. This finding posed the diagnosis of TO while RUL lesion was cleared by antibiotic treatment. Case is reported because, to our knowledge, it represents a unique anatomic location of TO which was confined exclusively in the right main bronchus mucosa without affecting trachea.