A 52-yr-old man undergoing laparoscopic colectomy had a significant peritubal air leak after initiation of mechanical ventilation using a 7.5-size endotracheal tube (ETT). Peritubal air leak continued even after an 8.0-size ETT with excessive cuff inflation had been used. Multiple tracheal diverticula were detected during flexible bronchoscopy, and the tube was inserted beyond the diverticula. After excessive cuff inflation, leakage was limited to a clinically acceptable value. Preoperative computed tomography revealed Mounier–Kuhn syndrome with multiple tracheal diverticula (fig. 1, A to C, red arrows).

Fig. 1.
Preoperative radiography of the patient. (A) Axial views of chest computed tomography at the level of multiple diverticula (upper panel), below the diverticulum (middle panel), and main bronchi level (lower panel). (B) Reconstructed coronal views of chest computed tomography. (C) Three-dimensional reconstruction chest computed tomography. The red arrows point to the multiple diverticula.

Preoperative radiography of the patient. (A) Axial views of chest computed tomography at the level of multiple diverticula (upper panel), below the diverticulum (middle panel), and main bronchi level (lower panel). (B) Reconstructed coronal views of chest computed tomography. (C) Three-dimensional reconstruction chest computed tomography. The red arrows point to the multiple diverticula.

Mounier–Kuhn syndrome is characterized by marked dilatation of the trachea and main bronchi resulting from thinning or atrophy of elastic fibers and smooth muscles. Mounier–Kuhn syndrome is diagnosed based on computed tomography findings of the transverse tracheal diameter exceeding 30 mm and right and left main bronchi diameters exceeding 24 and 23 mm, respectively  (fig. 1, A and B). Mounier–Kuhn syndrome can be associated with multiple tracheal diverticula. The condition of patients with Mounier–Kuhn syndrome is exacerbated by a tracheal diverticulum, which may act as a reservoir of secretions. 

The reported methods for reducing gas leakage and pulmonary aspiration in patients with Mounier–Kuhn syndrome include charging the throat with wet gauze, applying a laryngeal mask, subglottic placement of a large ETT, and excessive inflation of the tube cuff.  However, when ETT is used in a patient with Mounier–Kuhn syndrome with multiple tracheal diverticula, the diverticula can complicate the airway management, because even the excessive inflated ETT cuff cannot prevent the air leak if the cuff is located on this excessively enlarged tracheal portion. In addition, anesthesiologists should pay attention to airway dilatation during the preoperative visit.