Trachea on CXR-Patient with Stridor

What are the findings in elderly male with history of wheezing?

Tracheal lumen despite malrotation and flexion of the neck looks abnormal focally in thoracic segment. The others include curvilinear calcification at the left heart border with no significant cardiomegaly along with left costopleural opacity

How do we explain and what is the important finding?

It is difficult to pinpoint extent of severity of individual findings in this patient at this time. However as the patient has reported for wheezing with possible expiratory stridor, I would suggest we concentrate on Trachea and ask for direct/ indirect tracheoscopy , fluoroscopy to see post wall collapse or CT chest or simply good lateral view and follow up x- rays ( if clinical situation permits)

Teaching points by Dr MGK Murthy, Resident-Professor Series.

· Trachea extends from cricoid(C6) to carina with inferior end dynamic and changes with inspiration/expiration coming up to D6 at times

· PA of Chest and true lateral with head hyperextended with high KVp(to get less of white bony thorax) are ideal. Unusual flexion of the neck specially in children produces buckled appearance (pseudomass )

· Triad of Anterior buckling of posterior tracheal wall, narrow AP dimension, and widened posterior membranous tracheal wall clinch tracheomalacia as diagnosis(fluoroscopy will help see unusual expiratory collapse)

· The other uncommon causes are usually pappillomatosis, leiomyoma, schwannoma, paraganglioma, melanoma, carcinoma and sarcomas(1 true tracheal tumor for every 140 bronchogenic carcinomas estimated )

· CT particularly in inspiration/ expiration is the imaging modality of choice

what about the heart and pleura in this case?

Incidental aneurysms in elderly age(this patient is 93 yrs old ) need echo correlation for evaluation and pleural thickening needs no follow up