INTRODUCTION: A posterior tracheal pouch, also known as tracheocele, is gas-containing out pouching of the trachea, mostly asymptomatic but can sometimes cause respiratory infections1. Diagnosis of tracheoceles can be done radiologically or by direct bronchoscopic visualization. Management for persistent symptomatic tracheal pouches typically includes antiobiotics and surgical resection.
CASE PRESENTATION: This is a 50 yr-old male who was referred to our institution from an out-of-state medical center for recurrent lower respiratory tract infections in the setting of a posterior tracheal opening thought to be a tracheoesophageal fistula. Initial work-up at our facility included an upper GI endoscopy which did not reveal any esophageal defects. A subsequent barium swallow also revealed no esophageal defects. The patient then underwent a bronchoscopy for a thorough airway examination and a posterior tracheal wall defect was visualized approximately 5 cm from the carina. The appearance was that of a transverse fold on the posterior tracheal wall. A flexible biopsy catheter was advanced through the working channel of the bronchoscope and used to lift and introduce the catheter into the fold. The catheter was advanced for approximately 1 cm before meeting resistance. A 4-french 100 cm in length angiographic catheter was inserted through the working channel of the flexible bronchoscope into the flap and 10 ml of barium was injected into the pouch under direct fluoroscopic visualization with no extravasation of barium or abnormal connections noted. The findings were discussed with the patient and the treatment options of surgical resection and endobronchial treatments to close the pouch using fibrin glue or alcohol based injections were reviewed. The decision was made to proceed with fibrin glue injection which was performed under flexible bronchoscopy guidance with a total of 3 ml delivered to the pouch via an angiographic catheter. The patient tolerated the procedure without any immediate complications. He is awaiting his 3 months follow-up visit and repeat flexible bronchoscopy.
DISCUSSION: Tracheal pouches are known by many names including tracheocele, tracheal diverticulum or paratracheal cyst. They are a gas-containing out pouching of the trachea, mostly asymptomatic, but may cause recurrent respiratory infections by accumulating infected material1. An autopsy series noted an incidence of 1%. Tracheoceles may either be congenital (i.e. aborted development of lung divisions) or acquired (i.e. increased intraluminal pressure, surgical). Tracheal pouches are usually diagnosed by CT scans or bronchoscopy as in our patient1. In asymptomatic cases, posterior tracheal pouches are managed conservatively, while symptomatic cases are initially treated with antibiotics. Persistent/recurrent infections stemming from these airway defects usually require surgical resection with considerable down time.
CONCLUSIONS: To our knowledge, this is the first reported case of an adult patient undergoing endoscopic management of a posterior tracheal pouch using fibrin glue injection. There is a reported case in the literature of a pediatric patient in Italy who underwent a similar procedure in 2010 with complete pouch closure and resolution of symptoms3.
Reference #1 1. Goo JM et al. Right paratracheal cyst in the thoracic inlet: Clinical and radiological significance. Am J Roentgenol. 1999.
Reference #2 2. Infante M et al. Tracheal diverticulum: A rare cause and consequence of chronic cough. Eur J Surg. 1994.
Reference #3 3. Berlucchi M et al. Endoscopic treatment of tracheocele in pediatric patients. Am J Otolaryngol. 2010.
DISCLOSURE: The following authors have nothing to disclose: Ryan Chua, Ali Khodabandeh, Ilan Yavitz, Ali Ashraf, Armin Ernst, Samaan Rafeq
To our knowledge, this is the first reported case of an adult patient undergoing endoscopic management of a posterior tracheal pouch using fibrin glue injection.