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Tracheal compression due to anomalous innominate artery in an adult Krishna B. Gupta, Diksha Tyagi, Deepak Prajapat, Vipul Kumar Department of Respiratory Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
ABSTRACT A 47‑year‑old‑female presented with dyspnea and unproductive cough for 4 months. General examination revealed pulsatile swelling in the midline below the thyroid cartilage present since childhood. Computed tomography‑angiography of the neck showed right innominate artery dilated, elongated and coursing above downward, anterior to the trachea below the thyroid, compressing the trachea and origin of the right subclavian artery higher up. A case of anomalous innominate artery causing symptomatic compression of the trachea in adults is a rare entity. KEY WORDS: Color Doppler, computed tomography angiography, innominate artery, subclavian artery Address for correspondence: Dr. Krishna B. Gupta, 18/6J Medical Campus, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India. E-mail: [email protected]
A 47‑year‑old‑female presented in chest Outpatient Department with the chief complaint of unproductive cough and shortness of breath for 4 months that was insidious in onset and gradually progressive in nature. She never smoked and had no history of exposure to indoor air pollution. She was diagnosed to have hypertension and put on treatment 4 months back in the form of monotherapy with amlodipine. She had not given any past history of pulmonary tuberculosis, coronary artery diseases or any significant chronic illness. On physical examination, a pulsatile swelling of size 5.5 cm × 6.6 cm × 5.5 cm was palpable in the midline neck below the thyroid. Her blood pressure was 160/120 mmHg, pulse rate was 86/min, respiratory rate was 24/min, body temperature was 37.0oC and SaO2 was 96% by pulse oximetry. Systemic examination revealed no abnormality. Laboratory examination revealed hemoglobin 12.9 gm%, TLC 4500 per cu mm, hematocrit 40% and ESR 25 mm in the 1st hour. The biochemistry panel revealed no abnormality. Sputum investigations for AFB direct smear and pyogenic culture were negative. Spirometry and echocardiography
revealed normal study. Chest radiograph revealed slight mediastinal widening [Figure 1].
QUESTION What is your diagnosis?
Access this article online Quick Response Code:
Website: www.lungindia.com DOI: 10.4103/0970-2113.142096
Figure 1: Chest radiograph showing slight mediastinal widening
Lung India • Vol 31 • Issue 4 • Oct - Dec 2014 419
Gupta, et al.: Tracheal compression due to anomalous innominate artery
a Figure 2: Ultrasonography of the neck showing the right innominate artery coursing anterior to the trachea
b
Figure 3: (a) Computed tomography (CT)-angiography showing origin of the right innominate artery medial to the superior vena cava. (b) CT-angiography showing the right innominate artery coursing upward in front of the trachea
ANSWER Color Doppler ultrasonography of the neck in view of neck swelling was performed, revealing that the pulsatile swelling in the midline was the dilated and elongated right innominate artery anomalous course passing anterior to the neck below the thyroid [Figure 2]. To evaluate further, a computed tomography (CT)‑angiography of the neck was performed, revealing that the origin of the right subclavian artery from the right innominate artery is higher than the normal origin and the innominate artery is coursing from above downward [Figure 3a and b].
DIAGNOSIS Anomalous innominate artery causing tracheal compression. Anomalous innominate artery causing tracheal compression is commonly seen in children less than 2 years, but it is a rare diagnosis in adults.[1] Mostly, the adult patients
420
are asymptomatic and detected incidentally during surgical procedures. Such anomalies should be suspected in a patient presenting with respiratory symptoms with a near‑normal chest radiograph. The diagnosis can be easily confirmed by CT angiography. Medical management includes humidified oxygen, steroids and antibiotics, while common surgical approaches include arteriopexy, with suspension of the innominate artery to the sternum or reimplantation at a more proximal site of the ascending aorta.
REFERENCE 1.
Joseph H, Louis NG, Ruth M. Case of an anomalous innominate artery causing tracheal compression in an adult, misdiagnosed as chronic obstructive pulmonary disease. Chest 2009;136(4_MeetingAbstracts).
How to cite this article: Gupta KB, Tyagi D, Prajapat D, Kumar V. Tracheal compression due to anomalous innominate artery in an adult. Lung India 2014;31:419-20. Source of Support: Nil, Conflict of Interest: None declared.
Lung India • Vol 31 • Issue 4 • Oct - Dec 2014
Copyright of Lung India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Tracheal compression due to anomalous innominate artery in an adult Krishna B. Gupta, Diksha Tyagi, Deepak Prajapat, Vipul Kumar Department of Respiratory Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
ABSTRACT A 47‑year‑old‑female presented with dyspnea and unproductive cough for 4 months. General examination revealed pulsatile swelling in the midline below the thyroid cartilage present since childhood. Computed tomography‑angiography of the neck showed right innominate artery dilated, elongated and coursing above downward, anterior to the trachea below the thyroid, compressing the trachea and origin of the right subclavian artery higher up. A case of anomalous innominate artery causing symptomatic compression of the trachea in adults is a rare entity. KEY WORDS: Color Doppler, computed tomography angiography, innominate artery, subclavian artery Address for correspondence: Dr. Krishna B. Gupta, 18/6J Medical Campus, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India. E-mail: [email protected]
A 47‑year‑old‑female presented in chest Outpatient Department with the chief complaint of unproductive cough and shortness of breath for 4 months that was insidious in onset and gradually progressive in nature. She never smoked and had no history of exposure to indoor air pollution. She was diagnosed to have hypertension and put on treatment 4 months back in the form of monotherapy with amlodipine. She had not given any past history of pulmonary tuberculosis, coronary artery diseases or any significant chronic illness. On physical examination, a pulsatile swelling of size 5.5 cm × 6.6 cm × 5.5 cm was palpable in the midline neck below the thyroid. Her blood pressure was 160/120 mmHg, pulse rate was 86/min, respiratory rate was 24/min, body temperature was 37.0oC and SaO2 was 96% by pulse oximetry. Systemic examination revealed no abnormality. Laboratory examination revealed hemoglobin 12.9 gm%, TLC 4500 per cu mm, hematocrit 40% and ESR 25 mm in the 1st hour. The biochemistry panel revealed no abnormality. Sputum investigations for AFB direct smear and pyogenic culture were negative. Spirometry and echocardiography
revealed normal study. Chest radiograph revealed slight mediastinal widening [Figure 1].
QUESTION What is your diagnosis?
Access this article online Quick Response Code:
Website: www.lungindia.com DOI: 10.4103/0970-2113.142096
Figure 1: Chest radiograph showing slight mediastinal widening
Lung India • Vol 31 • Issue 4 • Oct - Dec 2014 419
Gupta, et al.: Tracheal compression due to anomalous innominate artery
a Figure 2: Ultrasonography of the neck showing the right innominate artery coursing anterior to the trachea
b
Figure 3: (a) Computed tomography (CT)-angiography showing origin of the right innominate artery medial to the superior vena cava. (b) CT-angiography showing the right innominate artery coursing upward in front of the trachea
ANSWER Color Doppler ultrasonography of the neck in view of neck swelling was performed, revealing that the pulsatile swelling in the midline was the dilated and elongated right innominate artery anomalous course passing anterior to the neck below the thyroid [Figure 2]. To evaluate further, a computed tomography (CT)‑angiography of the neck was performed, revealing that the origin of the right subclavian artery from the right innominate artery is higher than the normal origin and the innominate artery is coursing from above downward [Figure 3a and b].
DIAGNOSIS Anomalous innominate artery causing tracheal compression. Anomalous innominate artery causing tracheal compression is commonly seen in children less than 2 years, but it is a rare diagnosis in adults.[1] Mostly, the adult patients
420
are asymptomatic and detected incidentally during surgical procedures. Such anomalies should be suspected in a patient presenting with respiratory symptoms with a near‑normal chest radiograph. The diagnosis can be easily confirmed by CT angiography. Medical management includes humidified oxygen, steroids and antibiotics, while common surgical approaches include arteriopexy, with suspension of the innominate artery to the sternum or reimplantation at a more proximal site of the ascending aorta.
REFERENCE 1.
Joseph H, Louis NG, Ruth M. Case of an anomalous innominate artery causing tracheal compression in an adult, misdiagnosed as chronic obstructive pulmonary disease. Chest 2009;136(4_MeetingAbstracts).
How to cite this article: Gupta KB, Tyagi D, Prajapat D, Kumar V. Tracheal compression due to anomalous innominate artery in an adult. Lung India 2014;31:419-20. Source of Support: Nil, Conflict of Interest: None declared.
Lung India • Vol 31 • Issue 4 • Oct - Dec 2014
Copyright of Lung India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
