Pneumomediastinum, Tracheal Diverticulum, and Probable Asthma: Coincidence or Possible Association? A Case Report

Abstract

Patient: Male, 25Final Diagnosis: Spontaneous pneumomediastinumSymptoms: Chest discomfort • exertional dyspnea • wheezingMedication: —Clinical Procedure: —Specialty: PulmonologyObjective:Rare co-existance of disease or pathologyBackground:Many conditions and triggers have been identified and associated with spontaneous pneumomediastinum (SPM), including asthma, strenuous exercise, chronic obstructive pulmonary disease, diabetic ketoacidosis, inhalational drugs, and other activities associated with the Valsalva maneuver. Among rare findings reported in patients with SPM is tracheal diverticulum. We present a case of SPM that on further evaluation was noted to have a tracheal diverticulum, together with a possible diagnosis of asthma.Case Report:A 25-year-old male was admitted to the hospital for dyspnea and chest pain. Based on initial assessment, laboratory findings, and imaging, he was diagnosed with SPM. Recovery was successful, and the patient was discharged 3 days later. Follow-up at 2 weeks revealed an abnormality on imaging and abnormal pulmonary function tests. A computed tomography scan revealed a tracheal diverticulum located on the right postero-lateral region of the trachea at T1 level. Pulmonary function tests abnormalities included: high fractional exhaled nitric oxide (FeNO), high lung clearance index (LCI), and elevated diffusing capacity of the lungs for carbon monoxide (DLCO).Conclusions:Although the patient presented with a normal spirometry, the FeNO, LCI, and DLCO findings proved valuable and suggested a possible diagnosis of asthma. The anatomic weakness associated with the tracheal diverticulum could have been the breaking point of sustained increased pressure in the airways, due to a possible asthma exacerbation. In retrospective, we hypothesized this to be a series of events that ultimately ended as a pneumomediastinum.

Chronic Cough Revealing a Tracheal Diverticulum: A Case Report

“…Their wall is made of cartilage, smooth muscle, and epithelium, similar to that of the trachea. Furthermore, 98% are positioned next to the vertebrae T1-T3, above the carina, or 4 to 5 cm below the vocal cords [1,5,[10][11][12].…”

“…Unlike congenital TDs, they are larger, with wider openings to the tracheal lumen and thinner walls made exclusively of epithelium. In addition, they occur at different localizations of the trachea and are rarely multiple [1,5,10,11]. In fact, the increase in intraluminal pressure responsible for TD may be due to chronic coughing or weakened structures secondary to tracheal surgical procedures, leading to an external invagination of the mucous membrane through vulnerable points of the trachea [13,14].…”

Tracheal Diverticulum in SARS-CoV-2 Patients on Non-Invasive Ventilation A not so “Spontaneous” Cause of Pneumomediastinum? An imaging Pictorial Presentation of Two Cases with Review of Literature

“…The incidence of incidentally detected tracheal diverticula is up to 6% [4]. There have been isolated case reports in the past where pneumomediastinum and tracheal diverticula were incidentally detected [5][6][7][8]. Some of these cases of diverticula and pneumomediastinum were in patients after endotracheal intubation and ventilation [7].…”

Multiple Tracheal Diverticula in a COVID-19 Positive Patient

“…Tracheal diverticulas are a rare type of paratracheal air cysts with an incidence of 1% to 4%. 1 -9 They present as air-filled cystic formations in the paratracheal region, usually connected to the tracheal lumen. In 97% of the cases, they appear on the right posterolateral side of the trachea, due to lack of support from the esophagus and absence of cartilaginous tissue.…”

“…Furthermore, 98% are located at the vertebral level T1 to T3, 4 to 5 cm below the vocal folds or above the carina. 2 -4,6,10…”