Tracheomalacia Workup

Updated: Apr 28, 2020
  • Author: Daniel S Schwartz, MD, MBA, FACS; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
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Workup

Imaging Studies

Chest radiography

Chest radiography may demonstrate hyperinflation, excessive narrowing of the tracheal lumen during expiration, or vascular anomalies such as double aortic arch; further evaluation usually is required. (See the images below.)

Lateral chest radiograph shows excessive tracheal Lateral chest radiograph shows excessive tracheal narrowing.
This shows the trachea during inspiration and expi This shows the trachea during inspiration and expiration. Tracheal collapse of more than 50% during expiration is diagnostic of tracheomalacia.
A 58-year-old woman with a history of polychondrit A 58-year-old woman with a history of polychondritis presented with inspiratory stridor and respiratory difficulties. The chest radiograph shows narrowing of the distal trachea on bronchoscopy. More than a 50% decrease in tracheal lumen occurred during expiration (see CT images).

Cinefluoroscopy

Cinefluoroscopy performed with contrast in the esophagus utilizing quiet respiration and coughing has proved to be an optimal means of establishing a diagnosis. During coughing, more than half to complete collapse of tracheal lumen confirms the diagnosis. In addition to showing collapse of the tracheal wall, cinefluoroscopy may identify esophageal defects, and it may reveal deformation of tracheal contour due to vascular anomaly.

Computed tomography

The dynamic airway collapse is better appreciated with ultrafast computed tomography (CT). Dynamic expiratory CT elicits a larger degree of airway collapse than standard end-expiratory CT in patients with tracheobronchomalacia. Fourteen patients (11 men, 3 women; age range, 19-79 years) were included in a study to assess airway collapse for confirmation of a diagnosis of tracheobronchomalacia; dynamic expiratory CT revealed a significantly greater degree of airway collapse than end-expiratory CT. [9] (See the images below.)

The CT scan of a 58-year-old woman with a history The CT scan of a 58-year-old woman with a history of polychondritis who presented with inspiratory stridor and respiratory difficulties shows tracheal narrowing of the distal trachea.
CT image showing tracheal narrowing in a 58-year-o CT image showing tracheal narrowing in a 58-year-old woman with a history of polychondritis who presented with inspiratory stridor and respiratory difficulties.
A 3-dimensional reconstruction of CT scan images c A 3-dimensional reconstruction of CT scan images confirms the presence of tracheomalacia in a 58-year-old woman with a history of polychondritis who presented with inspiratory stridor and respiratory difficulties.
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Endoscopy

The definitive diagnosis of major airway depends on obtaining an accurate history combined with proper endoscopic evaluation (see the image below). The airway is directly visualized during spontaneous respiration using ventilating laryngoscope and telescoping bronchoscopy. Flexible bronchoscopy also may be utilized. The findings consist of the following classic triad:

  • Loss of normal semicircular shape of tracheal lumen
  • Forward ballooning of the posterior membranous wall
  • Anteroposterior narrowing of the tracheal lumen
Healthy trachea is visualized endoscopically. Healthy trachea is visualized endoscopically.
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Other Tests

In pulmonary function testing, the flow-volume curve, though usually performed in adults rather than children, may demonstrate a normal inspiratory curve but a truncated expiratory limb.

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