Anesthesiologists preparing a patient for robotic surgery had what should have been an ideal setup. A video laryngoscope gave them a clear view of the airway. Yet the breathing tube would not advance.
The cause, doctors at Cardarelli Hospital in Naples, Italy, later found, was a previously unrecognized disease called tracheobronchopathia osteochondroplastica (TO), in which hard nodules of cartilage and bone grow along the inside of the windpipe and main airways. The team described the case in a report in Clinical Case Reports published Sept. 23, 2026.
A Clear View That Did Not Solve the Problem
Difficult intubations are usually blamed on anatomy that makes the vocal cords hard to see, such as a small jaw, limited neck movement or swelling. Video laryngoscopes are designed to overcome that problem.
In this case, seeing was not the issue. The report describes an "unexpected failure of endotracheal tube advancement despite optimal videolaryngoscopic visualization." The obstruction lay beyond the vocal cords, inside the trachea itself, where the nodules narrowed the passage.
Bronchoscopy, which uses a camera to look directly inside the airways, established the diagnosis. The same approach led to the definitive fix: the team treated the condition with rigid bronchoscopy.
Rigid bronchoscopy differs from the more familiar flexible version. It uses a straight, hollow metal tube and is often done while the patient is under general anesthesia. The rigid scope gives specialists more room to work, which can help when a segment of the airway needs to be opened or cleared of obstructing tissue.
A Disease That Can Hide for Years
TO is rare, and much of what is known about it comes from small case series. A 2021 report from Kyushu University in Japan, published in the American Journal of Case Reports, noted that TO "was reported in 0.4% of performed bronchoscopies" but added that its frequency is actually higher. Many people with the condition have no symptoms or only vague ones.
That silence is the central problem. A study from Samsung Medical Center in Seoul, published in the Journal of Thoracic Disease in 2020, followed 40 patients diagnosed from 1997 to 2019. Just over half, 52.5%, had no symptoms at diagnosis. Others had cough, shortness of breath with exertion, increased sputum or coughing up blood. The median age was 63, and 65% were men.
The disease also tends to progress slowly. In the Korean study, only 10% of patients saw their symptoms worsen during follow-up, and the authors concluded that it "is well managed with conservative therapies." Only two of the 40 received laser treatment.
In other words, many people with TO may live for years without knowing they have it. Sometimes the first clue comes when someone tries to pass a tube through the airway.
The Telltale Pattern Inside the Windpipe
The nodules have a distinctive appearance. Because they arise from cartilage, they typically spare the back wall of the trachea, which is made of soft membrane rather than cartilage rings. A 2024 case report in Frontiers in Medicine, which uses the condition's alternate name, tracheobronchopathia osteoplastica, described CT scans showing "multiple calcified and non-calcified nodules protruding into the lumen of the trachea and main bronchi" while sparing that membranous wall.
The cause remains unknown. Researchers have proposed factors such as chronic infection and inflammation, but no single trigger has been established. The same report observed that "most patients do not exhibit obvious symptoms or may only have a mild cough," and that the disease progresses slowly and carries a good prognosis.
The Naples case is not the first time TO has complicated anesthesia. The 2021 Japanese report described a 67-year-old man with known TO who was scheduled for robot-assisted prostatectomy. Three years earlier, during heart surgery, his breathing tube had met considerable resistance and was placed with the help of an introducer device. This time, a 6.5-mm spiral breathing tube met resistance where the airway narrowed to 9 mm, about 1 cm below the vocal cords. The team succeeded by gently rotating a standard 6.5-mm tube, with a bronchoscope assisting.
Knowing When to Stop Pushing
The Italian authors stress a practical lesson for anesthesiologists: suspect hidden tracheal disease when a tube will not pass despite a good view, and avoid "repeated traumatic intubation attempts." Forcing a tube against rigid nodules can injure the airway lining.
For patients, the case is not a reason for alarm. TO is uncommon, often causes no symptoms for years and typically moves slowly. But it does show how routine procedures can uncover conditions that were never suspected.
People who have been told of a difficult intubation during a previous surgery should share that information with their care team before any future procedure. Anyone with unexplained, long-lasting cough, wheezing or coughing up blood should discuss it with a clinician, who can decide whether airway imaging or bronchoscopy is warranted.
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Key Questions Answered
What happened during this surgery?
Anesthesiologists had a clear video view of the airway, but the breathing tube would not advance. Bronchoscopy revealed a previously unrecognized airway disease, which the team then treated with rigid bronchoscopy.
What is tracheobronchopathia osteochondroplastica?
It is a rare, benign condition in which nodules of cartilage and bone form along the inner walls of the trachea and main bronchi, usually sparing the back wall.
How common is it?
It has been reported in about 0.4% of bronchoscopies, though it is likely underdiagnosed because many people have no symptoms.
What symptoms does it cause?
Many patients have none. Others may have chronic cough, shortness of breath with exertion, sputum or coughing up blood.
Is it dangerous?
It usually progresses slowly and is often managed conservatively. It can complicate intubation, and significant narrowing may require bronchoscopic treatment.
What should patients do if they had a difficult intubation before?
They should tell their surgical and anesthesia team ahead of any future procedure so the airway can be planned for in advance.
Published by Medicaldaily.com
