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Clinical Problem Solving: Radiology
October 2004

Radiology Quiz Case 1

Author Affiliations
 

R. NICKBRYANMDPATRICIA A.HUDGINSMD

Arch Otolaryngol Head Neck Surg. 2004;130(10):1236. doi:10.1001/archotol.130.10.1236

A girl was delivered by cesarean section to a gravida 2, otherwise healthy woman after 39 weeks of gestation. The pregnancy was complicated by tobacco and cannabis use during the first trimester. The Apgar scores were 6 and 8 at 1 and 5 minutes, respectively. The neonate became cyanotic and a 3.5 endotracheal tube was placed on day 1 of life. She was then transferred to our neonatal intensive care unit, where she did well and underwent extubation that same day. She subsequently developed respiratory distress and underwent reintubation with a 3.0 endotracheal tube. During the extubation period, biphasic stridor with substernal retractions occurred. On day 4 of life, the patient was evaluated by pediatric otolaryngology as she had become hypoxic and hypercarbic. Physical examination revealed an intubated, normally developed girl with bilateral coarse breath sounds. The findings of flexible nasopharyngolaryngoscopy were normal. Tracheobronchoscopy with a 2.2-mm flexible fiberoptic scope revealed an external compression of the tracheal lumen and a narrowing of the anterior-posterior diameter at the junction between the middle and distal thirds of the trachea (Figure 1), with a resumption of normal tracheal anatomy 5 mm proximal to the carina. The distal bronchial tree was normal. An echocardiogram (Figure 2) revealed the source of compression. Cardiothoracic surgery was consulted and corrective surgery was performed. Postoperative tracheobronchoscopy demonstrated resolution of the compression and restoration of the tracheal framework as manifested by a patent tracheal lumen and a normal anterior-posterior diameter (Figure 3).

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