CASE FOR DIAGNOSIS Recurrent tracheal mass

In 1994 a 44-yr-old male was admitted for surgical resection of a hard, not painful, nodule which was believed to originate from the isthmus of the thyroid gland. He was known to have mild asthma, treated with inhaled corticosteroids and shortacting b2-agonists. His medical record revealed a smoking history of 20 pack-yrs. The patient denied any other symptoms, except the presence of the nodule. On physical examination a hard nodule was felt anteriorly to the trachea. A clear separation with the thyroid gland could not be made. A preoperative computed tomography (CT) scan of the neck revealed a calcified nodule on the midline, adjacent to the trachea (fig. 1). Laboratory studies demonstrated a euthyroid status. During surgery, the nodule could not be separated from the tracheal cartilaginous ring and a left hemithyroidectomy, with resection of part of the affected cartilaginous ring, was carried out (histology of the nodule in fig. 2a). The tracheal defect was closed with a muscle flap. The patient continued to do well on follow-up examinations f5 yrs postoperatively, without complaints. Repeated bronchoscopy examinations confirmed the tracheal integrity. After 5 yrs the patient was lost to follow-up. Seven years after his first operation the patient reported cough, blood-speckled sputum and dyspnoea on exertion. Physical examination revealed inspiratory wheezes (stridor) over the cervical trachea. Spirometry with flow/volume loop analysis (fig. 3), bronchoscopy (fig. 4) and a CT scan of the neck (fig. 5) were performed. The histology of the resection specimen is shown in figure 2b.