While tracheostomy tube cuff overinflation is usually a clinical diagnosis based on cuff pressures, imaging criteria have been proposed (please refer to the questions and answers above). This case shows marked overinflation of the cuff. Chronic overinflation has likely caused breakdown of the posterior tracheal wall, intrathoracic tracheitis and aspirated secretions. The esophagus appears compressed and deviated to the left at the level of the overinflated cuff. No definite esophageal erosion or fistula is seen, although this is difficult to assess on CT. The upper thoracic vertebrae are eroded.

Right thoracentesis yielded purulent fluid and grew Proteus mirabilis. This organism is part of the normal gastrointestinal flora and rarely causes empyema; thus a tracheo-esophageal fistula was suspected clinically. A right chest tube was placed and the patient was treated with antibiotics. The cuff was not deflated as doing so could result in further complications.

Case co-author: William Chan, MD (Loyola University Medical Center)