INTRODUCTION

Calcification of the trachea and proximal bronchi is a com-mon, normal finding on chest radiographs in the elderlypopulation, especially in women (1). It usually appeared af-ter the age of 60 and have not much clinical significance.Histologic findings in autopsied cases showed the calcifica-tions and ossifications to be in the cartilaginous rings them-selves (2).

More extensive airway calcification is also a rare mani-festation of many pathologic conditions (1). In this article,

a rare condition of post-tracheotomy calcification case wasreported with a detailed literature survey. We could notfind a similar case in the literature.

CASE REPORT

A 42-year-old man was seen at the OtorhinolaryngologyDepartment of Kirikkale University Faculty of Medicine forConsultation from the Urology Department. He had uret-

hral stenosis and was planned to undergo urethral dilatati-on. There were tracheotomy scar on the neck (Figure 1) and

ABSTRACTCalcification of the trachea is a common finding on chest radiographs

in the elderly population, especially in women. Post-tracheotomy trac-

heal calcification is a very rare condition. In this case report, a 42-year-

old man who had urethral stenosis and was planned to undergo uret-

hral dilatation, having scar on the neck due to previous tracheotomy,

was reported. Tracheotomy was performed after the accident. After 1month, he was decannulated and tracheotomy was closed. In recent

position, he had no respiratory problems during physical examinations

or at rest. After endoscopic laryngeal evaluation, larynx and trachea

were evaluated with high resolution computed tomography (HRCT).

At the level of cervical 7th-thoracal 1st vertebraes, previous tracheo-

tomy tractus was seen with the calcifications on the anterior and late-ral borders of the trachea. In the tracheal lumen, there were not any

strictures, any narrowness and any deformities at the contours. It was

kept in mind that in the patients, performed previous tracheotomy,

there may be tracheal calcification in the operation site.

Key words: Tracheotomy, calcification, tomography

Corresponding Address:

Dr. Nuray Bayar MulukBirlik Mahallesi, Zirvekent 2. Etap Sitesi, C-3 Blok, No: 62/43 06610 Çankaya/Ankara/TurkeyTel: +90 0312 496 40 73 • GSM: +90 0532 718 24 41 • Fax: +90 318 225 28 19 • e-mail: nbayarmuluk@yahoo.com1 Professor in Kirikkale University, Faculty of Medicine, ENT Department2 Associate professor in Kirikkale University, Faculty of Medicine, Urology Department3 Associate professor in Kirikkale University, Faculty of Medicine, ENT Department4 Assistant doctor in Kirikkale University, Faculty of Medicine, ENT Department

Dr. Nuray Bayar Muluk1 • Dr. Erdal Y›lmaz1 • Dr. Osman Kürflat Ar›kan2 • Dr. O¤uzhan Dikici3 • Dr. Özge Özata4

Bidder T›p Bilimleri Dergisi

2009 • Y›l: 1 • Say›: 3 • 30-32

POST-TRACHEOTOMY TRACHEAL CALCIFICATIONS: A CASE REPORTTRAKEOTOM‹ SONRASI TRAKEAL KALS‹F‹KASYONLAR:OLGU SUNUMU

CASE REPORT

ÖZETTrakeal kalsifikasyon yafll› hastalarda, özellikle kad›nlarda akci¤er gra-

fisinde normalde görülebilen bir durumdur. Trakeotomi sonras› trake-

al kalsifikasyon, nadir görülen bir durumdur. Bu olgu sunumunda,

üretral stenoz nedeni ile üretral dilatasyon planlanan ve önceden yap›l-

m›fl olan trakeotomi nedeni ile boyunda skar bulunan olan 42 yafl›nda-

ki erkek hasta sunulmufltur. Geçirilmifl kazay› takiben trakeotomi aç›-lan hasta 1 ay sonra dekanüle edilmifl ve trakeotomi kapat›lm›flt›r.

Mevcut durumda, hastan›n solunum güçlü¤ü bulunmamaktad›r. En-

doskopik larengeal de¤erlendirmeyi takiben, larenks ve trakea yüksek

rezolüsyonlu bilgisayarl› tomografi (HRCT) ile de¤erlendirilmifltir.

Servikal 7–Torakal 1. vertebra seviyesinde, daha önce aç›lm›fl olan tra-

keotomi trakt›; ve trakean›n anterior ve lateral kenarlar›nda kalsifikas-yonlar gösterilmifltir. Trakeal lümende herhangi bir striktür, darl›k ve

deformite saptanmam›flt›r. Trakeotomi yap›lan hastalarda, operasyon

bölgesinde trakeal kalsifikasyon bulunabilece¤i ak›lda tutulmal›d›r.

Anahtar kelimeler: Trakeotomi, kalsifikasyon, tomografi

OLGU SUNUMU

30 Bidder T›p Bilimleri Dergisi

they wanted to know if there would be any problems duringthe operation of the patient under spinal or general anest-hesia.

In patients history, he had a traffic accidant in 2002.Tracheotomy was performed after the accident. After 1month, he was decannulated and tracheotomy was closed.In recent position, he had no respiratory problems duringphysical examinations and/or at rest.

Patient was initially examined by indirect laryngoscopyand later endoscopic laryngeal evaluation. Laryngeal endos-copy was assessed by Storz, Karl-Storz Endoskope (Tele-Laryngo-Pharyngoskope 8707DJ-Germany). No anaesthe-sic agent was used during endoscopy. All of the laryngealstructures; and movements of the true vocal folds and ary-tenoids were normal. There were tracheotomy scar on theantero-inferior part of the neck just 2 cm above the sternalnotch. The remainder of the head and neck examinationfindings were normal.

Larynx and trachea were evaluated with high resolutioncomputed tomography (HRCT). At the level of cervical7th-thoracal 1st vertebraes, previous tracheotomy tractuswas seen with the calcifications on the anterior and lateralborders of the trachea (Figures 2, 3). In the tracheal lumen,there were not any strictures, any narrowness and any de-formities at the contours.

As a result, tracheal lumen was sufficient enough for thepatient’s respiration and there were no problems or comp-lications during patients urethral dilatation operation withspinal anesthesia.

The patient gave permission by written and signed forusing his all knowledge and photographs and graphies.

DISCUSSION

In the benign tracheobronchial lesions with calcificati-on, tracheobronchopathia osteochondroplastica, relapsingpolychondritis and tracheobronchial amyloidosis were con-sidered. Computed tomography (CT) demonstrated smallnodules with calcifications at the trachea with or withoutdeformity of tracheal wall in the case of tracheobronchopat-hia osteochondroplastica, swelling of tracheal cartilage withdiffuse and multiple calcifications in the case of relapsingpolychondritis and calcifications in the deep parts of trac-heobronchial amyloid nodules (3).

CT findings were able to differentiate those benign lesi-ons. HRCT is more useful in the distribution of abnormalcalcification of these diseases (3). In the present study, trac-heotomy tractus was demonstrated by HRCT.

In the present case, we reported tracheal calcification se-condary to the tracheotomy. Late complications of the trac-heotomy were bleeding, tracheomalacia, stenosis, tracheoe-sophageal fistula, tracheocutaneous fistula, granulation andfailure to decannulate (4). We could not find any informa-tion about late phase tracheal calcifications.

Pedersen, et al. (5) described a case in which a repeatminitracheotomy (MT) could not be performed 2 monthsafter the first. The cricothyroid membrane seemed calcifiedand histological examination showed scar formation withdystrophic calcification and heterotopic bone formation.Scar formation following MT may have caused these altera-tions making repeat access to the airway through the mem-brane impossible.

In our study, it seems that there was dystrophic calcifi-cation which occurred after the healing process of the trac-heotomy closure. Tracheitis, present in all patients withfresh tracheostomies, may have increased the tissue dama-ge; and also, tracheal lesions may be caused by pressure

312009 • Cilt: 1 • Say›: 3 • 30-32

Figure 1— Tracheotomy scar on the antero-inferior part of theneck just 2 cm above the sternal notch.

Figure 2— Tracheotomy tractus was demonstrated with thecalcifications on the anterior and lateral borders of the tracheaby axial HRCT.

32 Bidder T›p Bilimleri Dergisi

from the cuff of the tracheotomy tube (4). We should re-commend that careful post-operative care of the operation

site may help to reduce the amount of the calcification.When tracheotomy performed by the removal of a part

of the tracheal cartilage, unless exessive amount of calcifica-tion, this calcification may help to continue the strength of

the cartilage airway skeleton in trachea. But, if the need ofthe secondary tracheotomy occurs, the surgeon must know

about the calcification process and do the operation very

carefully. And also, since any of the damage to the trachealcartilages results in calcifications, we must be very carefulnot to damage tracheal cartilages during other head andneck operations to avoid from calcification.

Progressive calcification of the cartilaginous rings(CCR) of the trachea and bronchi has been observed in pa-tients undergoing prolonged prophylactic anticoagulanttherapy with warfarin sodium (6). Therefore, we recom-mend not to use this treatment in patients who had previo-us tracheotomy operation.

REFERENCES

1. Thoongsuwan N, Stern EJ. Warfarin-induced tracheobronchi-al calcification. J Thorac Imaging 2003;18:110-2.

2. Fukuya T, Mihara F, Kudo S, et al. Tracheobronchial calcifica-tion in members of a fixed population sample. Acta Radiol1989;30:277-80.

3. Ohkubo Y, Narimatsu A, Higuchi M, et al. CT findings of thebenign tracheobronchial lesions with calcification. RinshoHoshasen. 1990;35:839-46.

4. Cummings CW, Fredrickson JM, Harker LA, Krause CJ,Schuller DE, Richardson MA (Eds.). Otolaryngology Head &Neck Surgery, vol III, 3rd edition. St Louis: Mosby, 1998.

5. Pedersen J, Lou H, Schurizek BA, Melsen NC, Juhl B. Ossifica-tion of the cricothyroid membrane following minitracheo-tomy. Intensive Care Med 1989;15:272-3.

6. Moncada RM, Venta LA, Venta ER, Fareed J, Walenga JM,Messmore HL. Tracheal and bronchial cartilaginous rings:warfarin sodium-induced calcification. Radiology1992;184:437-9.

Figure 3— Tracheal calcifications at the tracheotomy site wereshown on axial HRCT.