Tracheal tumors are exceedingly rare and often overlooked as a cause of pulmonary symptoms until they reach an advanced stage. Most patients present with symptoms suggestive of asthma and the correct diagnosis is often made when the patient fails to respond to conventional asthma treatment.
Patient 1 is a 66 year old gentleman who presented with nocturnal “noisy breathing” and dyspnoea. He had been treated for “uncontrolled” asthma for 3 years. When his symptoms worsened, a computed tomography (CT) scan of the thorax was performed and showed a tumor measuring 5 cm below the vocal cords, located posterolaterally and extending extraluminally outside the trachea. The lesion was occupying 60% of the lumen. Tracheal resection with primary anastomosis following suprahyoid release and mobilization of the thyroid gland was performed. Operative findings were of a hard but well-encapsulated tumor located 5 cm below the vocal cords and attached to the right lateral wall. The tumor extended about 3 cm distally. Histopathological diagnosis was pleomorphic adenoma. The patient made an uneventful postoperative recovery and remains well 2 years after surgery. Patient 2 is a 38 year old lady who was treated for daily attacks of “asthma” and presented with “status asthmaticus” requiring endotracheal intubation and ventilatory support. Her peak airway pressures were persistently high and a flexible bronchoscopy showed an endobronchial tumor in the distal third of the trachea about 10 cm above the carina. Subsequently, a CT thorax showed an eccentric narrowing of the distal trachea consistent with tumor. A right thoracotomy and distal tracheal resection with primary anastomosis was performed. At operation, a polypoidal tumor measuring 2 x 2 cm with a broad base was noted arising from the left posterolateral aspect of the trachea. Histological diagnosis was mucoepidermoid carcinoma. She went on to make an uneventful recovery. Patient 3 is a 14 year old girl who had “poorly controlled” asthma for 2 years. CT thorax showed a tumor in the distal trachea. Flexible bronchoscopy and biopsy showed mucoepidermoid carcinoma. The patient underwent right thoracotomy and distal tracheal resection with primary anastomosis. Post-operative recovery was uneventful and the patient continues to be well 5 years after surgery.
Primary tracheal tumors are uncommon. Most patients are misdiagnosed as asthma and undergo numerous trials of unsuccessful conventional asthma treatment before further evaluation is undertaken leading to the correct diagnosis. In 2 of our patients, the diagnosis was initially made with CT imaging. The other patient required intubation and ventilatory support for “status asthmaticus”. She had persistently high peak airway pressures on ventilatory support and bronchoscopy revealed the tumor. Other diagnostic modalities include magnetic resonance imaging and fluoroscopy. Flow-volume curves may provide valuable data and aid in the diagnosis. Once the diagnosis is made, patients should be referred for surgery.
The majority of tracheal tumors misdiagnosed as asthma reported in the literature were diagnosed when flow-volume curves suggested a fixed airway obstruction resulting in further imaging studies for the patient. Our cases did not have flow-volume curve studies with further imaging studies performed when they failed to respond to conventional treatment. Whilst tracheal tumors are rare, they should be considered in the differential diagnosis in any patient who presents with late-onset asthma or patients with “asthma” who fail to improve despite appropriate treatment.
Atasha Asmat, None.