Recurrent Laryngeal Nerve Stretching in Tracheal Diverticulum: First Documented Mechanism of Hoarseness and Systematic Review of Literatures.

Tracheal diverticulum is a rare paratracheal air cyst. It is often asymptomatic. Large symptomatic cases may compress the recurrent laryngeal nerve (RLN) and cause hoarseness. It is a rare presentation, in < 0.2 cases per year in the world. We present a 45-year-old woman that had 6 months of chronic cough, dysphagia, odynophagia, dyspnea, hoarseness, hemoptysis, choking, and neck pain. She was not a smoker. Spirometry showed mild obstruction pattern (FEV1 78%). CT with 3D reconstruction revealed a 4 × 5 cm right posterolateral tracheal diverticulum (fifth-seventh rings, 8 mm communication). Bronchoscopy confirmed limited right vocal cord mobility. We did an open cervical excision that preserved the RLN. Histopathology confirmed acquired diverticulum. Hoarseness resolved in 3 weeks; repeat bronchoscopy showed normal vocal cord mobility. 3-month CT confirmed resolution; 1-year FEV1 improved. Asymptomatic at 12 months. Systematic review (1998-2025) found 4 prior hoarseness cases (total n = 5): 60% female, 80% right posterolateral, mean size 3.0 cm, 80% complete recovery in 3 weeks via open surgery. Largest reported diverticulum is with hoarseness. This is the first case with documentation of RLN stretching and quantitative improvement with spirometry. Multimodal imaging and early open excision with nerve preservation can cause excellent outcomes.