Tracheal diverticulum: An atypical presentation

A 46-year-old nonsmoking man was seen with recurrent episodes of hiccups and burping occurring for a 1-year period. A barium esophagogram showed external compression and deviation of the esophagus by an air-filled structure at the level of the thoracic inlet. No opacification of this structure with barium was seen (Figure 1). Computed tomographic scan of the chest showed that a septated cystic structure located to the right of the trachea and measuring 6 3 4.7 cm was causing compression of the upper esophagus and slight deviation of the trachea. A thin connection with the right posterolateral aspect of the trachea was demonstrated, consistent with tracheal diverticulum (Figure 2). Esophagoscopy showed no sign of an esophageal diverticulum. Bronchoscopy revealed a 3-mm ostium at the junction between the membranous and cartilaginous trachea approximately 7 cm proximal to the carina (Figure 3). Examination of the ostium with the endotracheal tube positioned proximally caused the patient’s neck to swell, confirming tracheal connection to the cyst. Resection of the diverticulum was approached through a cervical collar incision. The cyst was found to be in close apposition with the right side of the trachea. The lateral aspect extended past the right carotid artery and deep to the levelof the spine. Medially, the right recurrent laryngeal nerve was noted to be intimately adherent to the cyst. Once fully mobilized, the cyst was opened and the connection with the trachea was identified from within. A figure-ofeight polyglactin suture was placed to oversew the opening. The cyst was sharply excised circumferentially, preserving the recurrent laryngeal nerve. With the endotracheal tube proximal to our repair, the neck was filled with water and no air leak was noted. A fat pedicle from the neck was used to buttress the repair. Paratracheal diverticula or cysts are relatively rare, with a reported incidence of 1% in autopsy series. They most commonly occur in the right paratracheal region and can be subdivided into the categories of congenital